Like so much of current life, the practice of medicine has clearly entered the computer age. One need look no further to find examples of computers in medicine than the microprocessor-based watch, pager, or cell phone, the hospital information terminal where we get the results of computed tomography, or the security pad that accepts our code number or scans our identification badge to let us into the hospital after hours. Even our car keys have microprocessors to allow us to open the car door as we approach. Patients arrive at the office with computer printouts of information about their symptoms or disease gathered with ease from an Internet that contains more than 4.3 billion connected addresses. Computer technology has rapidly spread throughout the academic and the private sector of American medicine.^1,2 From the wards to the office to the coat pocket, computer technology is ubiquitous. A 1982 editorial in the British Medical Journal began with the statement, “Two assumptions seem to underlie all conferences on computers and medicine: first, that their wholesale introduction into all medical activities is inevitable; and secondly that they will be of great benefit.”³ Although the wholesale introduction of computers has not occurred and may not be inevitable, it is apparent that no field of medicine, including gynecology, can escape the influence of computer technology. Unfortunately, the validity of the assumption of universal benefit is much less certain. Despite widespread use and enthusiasm, the value of computers in most aspects of medical practice has yet to be proved, although the skeptics are less righteousness than they once were.

Although the introduction of computers into gynecology has lagged behind some other specialties, it is rapidly catching up. A survey by The American College of Obstetricians and Gynecologists (ACOG) demonstrated that most gynecologists are well aware of the potential of computers in the office setting.⁴ More than half of the ACOG members surveyed stated that they were already using computers or were planning to begin using them in the near future. More than 20,455 members (more than 44%) of ACOG have registered for access to the member's side of the ACOG Web site, and new registrations average more than 300 per week.

The Internet site averages more than 246,000 hits per day. In December 2002, the ACOG Web site had more than 7.6 million “hits.” That number has increased by seven million over the same period 2 years earlier. Although we are not yet at a stage in which it is essential for every gynecologist to use a computer, it is important for all physicians to at least be aware of what computers can and cannot do. A fundamental knowledge of medical computing will allow us to use this new technology more advantageously.

Computing technology continues to experience an exponential growth. Over the past several decades,Moore's law has described an important factor in this expansion.^5,6 Gordon Moore, a cofounder of Intel, noted in the mid 1960s that technology had been doubling the density of transistors on integrated circuits every 12 months. This meant that computers were periodically doubling in capacity and in speed per unit cost. In the mid 1970s, Moore revised his observation of the doubling time to a more accurate estimate of approximately 24 months, and that trend has persisted with minimal change through the end of the past century (Fig. 1).

Today's computers contain circuits connected by wires one-hundredth the size of a human hair. Single computer chips contain billions of diodes, capacitors, and transistors, yet often represent one of the smaller portions of the overall cost of the device. This explosion in capability, speed, and portability has made the microprocessor ubiquitous.

Processors: “The” Computer

Computer processors have been the most visible beneficiaries of the growth described by Moore's law. Many personal computers now can exceed speeds of one gigaflop (one billion additions or subtractions per second), a threshold that results in their being classified as “super computers” and restricting their export from the United States. The result of this growth of capacity is that now desktop and portable machines can display complex and moving images with ease, juggle multiple applications simultaneously (true multithreading), or grapple with elaborate computations or programming steps without noticeable slowing of response. These new machines easily handle large patient databases, patient education materials that include video and audio clips, and physician education modules that can simulate patient interactions such as ultrasonography, hysterography, and virtual reality.^7,8,9

Peripherals

Peripheral devices allow computers to gather and disseminate information. At one time, these were limited to printers, monitors, and modems. Peripheral devices now span the range of graphics tablets and fax machines to fetal monitors, blood pressure machines, personal assistants, cell phones, data gloves, and infrared communicators. These devices have expanded the capabilities of the computer and extended their reach into the practice of medicine. Devices now allow the practice of medicine at a distance^8,9 or enhance the delivery of care in traditional settings.¹⁰ Peripheral devices have even been used to replace other traditional technologies such as X-ray film^11,12 assist with neurosurgical procedures,¹³ or enhance colposcopy¹⁴ and the history¹⁵ and physical examination¹⁶ or evaluate competence in these areas.^17,18

Connecting to the Outside World

One “peripheral” that has changed medicine and everyday life has been the connection to the worldwide collections of computers and computer data known collectively as the Internet. The Internet has been described as a library card to the world.¹⁹ In the recent past, most of the activity of a computer was expended on manipulation information physically contained at the location of the computer, usually on data storage devices inside or connected to the point of use. Now the computer has become fundamentally a communication devise, processing information that is not physically present near the user. For physicians, the access to information with neither boundaries nor borders offers possibilities of professional education and growth that have never existed before.²⁰ These new opportunities range from the traditional, such as access to literature searches²¹ and reference libraries^22,23,24,25 to a growing list of entrepreneurial continuing education providers and collaborative research.²³

The most familiar use of the Internet in medicine is as a fast and efficient path for clinical reference. Many sites can provide access to full text transfer in addition to citations. Examples of this include site access provided as a benefit of traditional paper subscriptions (New England Journal of Medicine) and access provided as part of membership in an organization (ACOG). Simple software and ubiquitous Internet interfaces (browsers) have made it easy to obtain literature searches, online full text, online journals,²⁴ and access to images and photographs. From library computers, home or office sites, or by cellular telephone data links, it is possible to search through libraries around the world.²⁵ Many search engines are available to facilitate this function, but most physicians choose to access this type of information by way of a network or distant server that provides its own search facilities. The most common example in the office setting is accessing the medical literature using a database such as MEDLINE, PubMed, or Grateful Med. There are also specialized databases that contain a subset of the literature focusing on specific subjects. Examples include Toxline and the human genome project. In addition to providing easy access to current articles in the medical literature, they also allow access to a wide range of articles from nonmedical publications. Even full textbooks can now be accessed online.²⁶

Beyond the role of information transfer conduit, the Internet is enjoying a growing role in the education of students, residents, and graduate physicians. A number of sites offer lists of continuing education opportunities or directly provide the education online. Sites of this latter type include those that support forums for discussion, case studies (proctored and unproctored), or formal education programs.

Software is the general term applied to those collections of computer language instructions that tell the computer what tasks to perform on what type of data to obtain a desired result. Although there is more and more software that is specific to a particular segment of medicine, most is general or adapted from nonmedical applications.²⁷ Medical applications can be classified into four broad classifications: information processing, education, administration, and clinical uses.

Databases and the information that they contain drive much of information processing in medicine. Databases store, organize, sort, search, summarize, and report on a set of information. We make lists of things, but databases compile more extensive collections of information that may be manipulated in various ways, including the ability to manipulate the information in ways not anticipated when the information was collected. We might choose to organize a file drawer of patient files by name or identification number only to learn later that these might better be organized by zip code. A computer database can make that change virtually instantly. This approach to information management through readily available commercial software has seen many applications in obstetrics and gynecology. The database management programs currently available allow for a level of programming, error checking, and heuristic decision-making that make natural language outputs, such as narrative discharge summaries, to be generated from what was once viewed as raw data (Fig. 2).

One of the greatest abilities that computers have is the ability to convert and manage information in graphic, or visual, form. In medicine, graphic applications most often include data display and analysis, speaker support, and image processing. Slide production, graphic development, and computer-based presentations are becoming the rule, with many regional and national meetings no longer providing traditional slide projectors without advanced arrangements. Computer-generated images are also used for clinical care in diverse fields,^28,29,30 including the teaching of anatomy or trauma care.²⁹

The graphics capabilities of a super computer of 10 years ago can now be found in a child's video game system. This explosion of capability has endowed the personal computer with extraordinary abilities to create, modify, display, and transmit graphic images.^30,31 As a result, slide development, desktop publishing, the maintenance of teaching files of microscopic and macroscopic images, image manipulation, video capture, and other tasks have come within the reach of everyone. Physicians have put these abilities to work in the forms of speaker support, teaching files, the visible human project, practice newsletters, and the like. Graphics programs for the creation or modification of images begin at less than $50 but can range to several hundreds of dollars for three-dimensional rendering programs. Whatever the cost, programs of this type are readily available to anyone and may be run (in some form) on even the simplest of today's computers.

The term wetware has been applied to the intellectual, or brain-based, capabilities involved with the computing process. Whereas computing seems to be innate for anyone younger than 15, the skills required for effective computing are fully within the ken of all physicians. The largest impediment to becoming facile with computers is the proliferation of jargon associated with the field (Appendix). Once this hurdle is overcome, computing tends to become addictive. Newcomers to computing should be warned about this phenomenon and reassured that not all of life's tasks are better-managed through the application of microprocessor technology.

Expert Systems and Simulations

Expert systems are not intended to serve as computerized surrogates for physicians. Rather, they are designed to assist physicians in clinical decisions regarding diagnosis and treatment. When used in combination with good (human) clinical judgment, these programs can be effective clinical tools.³² At the same time, they can serve as a teaching aid, helping us to understand the thought process involved in clinical decision-making. Unfortunately, the development of expert systems in clinical medicine has proven to be extraordinarily difficult.³³ The few systems that have been developed have received only fair reviews^34,35,36 and little implementation.

In gynecology, most expert systems have been confined to relatively well-defined clinical problems. For instance, Chard developed a model expert system for the diagnosis of vaginal discharge.³⁵ For an academic exercise, he compared the diagnostic accuracy of his system versus medical and nonmedical personnel by generating sample cases to be solved by computer and by humans. Overall, the contest ended in a draw.

Riss and associates described two gynecologic expert systems.³⁶ One was developed for the timing of cycle stimulation for patients enrolled in their in vitro fertilization program, and the other was created for preoperative assessment of patients undergoing urinary incontinence procedures. URO-GEN, from the University of Virginia, is an expert system that deals with female urogenital symptoms, focusing on urinary tract infections, vulvovaginitis, salpingitis, and sexually transmitted disease.³⁷ The diagnosis of abnormal vaginal bleeding is another task attempted by gynecologic expert systems.^38,39 Other examples include Sexpert,⁴⁰ for the diagnosis and management of sexual dysfunction, and SELF⁴¹ (système en logique floue), which is a French program used for selecting and prescribing contraceptive methods. More recent projects have been of the predictive type, exemplified by efforts to predict fetal acidosis.⁴² Although there have been a number of projects in gynecology⁴³ and elsewhere,^44,45,46 the results have been disappointing and the widespread use of expert systems in clinical medicine appears a long way off.

Greater promise appears to be offered by using neural networks to solve clinical problems. This approach has been applied in a number of areas of medicine,^45,46 including a few in the field of obstetrics. Notable among these systems have been ones that estimate fetal weight,⁴⁷ predict fetal hematocrit in isoimmunized pregnancies,⁴⁸ and those that interpret nonstress tests⁴⁹ or manage labor.⁵⁰ Neural networks offer the possibility of developing an expert system when the exact relationships between factors are either unknown or unknowable.

The use of computers to simulate populations or clinical situations holds some promise for solving problems or predicting outcomes. This type of application has ranged from the effects of changing fee schedules⁵¹ to modeling physical performance.⁵² Simulations have also found application in medical education.⁵³

Risk Assessment

Risk assessment is another clinical assessment that can be performed with the aid of computer technology. Computer programs for generalized health-risk appraisal have been successfully implemented in various clinical settings for quite some time.⁵⁴ Other programs have focused on select topics as diverse as the risks of surgical procedures or hemochromatosis.⁵⁵ Selezneva and coworkers developed a computer program to assess the risk of postoperative complications specifically for patients undergoing gynecologic surgery.⁵⁶ Computer-assisted risk assessment is also useful in gynecology offices. For example, the risks of oral contraceptive medications can be calculated for individual patients based on age and past medical history, as with the SELF program described earlier. Diaz and coworkers designed a program for initial assessment of patients in a gynecologic clinic, focusing on general risk assessment and assessment of “reproductive health.”⁵⁷ However, as these authors point out, such programs must be carefully tested before being used in a clinical setting.

The most successful computer-based risk assessment tool in gynecology has been the Gail Model. This risk assessment model is available in formats for common computer platforms, including personal digital assistants (PDA). As prevalent as this program is, it is only one of a growing number of such programs that have been reported in the literature.⁵⁸

Dosing and Calculation

Several studies have demonstrated the usefulness of computers and calculators in drug dosage determination.^59,60 However, most of these studies have focused on the same few drugs: aminoglycosides, digitalis, and phenytoin. Computerized hospital order entry generally incorporates some elements of dosage verification. Most systems will also check for possible drug interactions⁶¹ and may provide elements of staff education based on the setting and drug ordered. Whereas the use of computer-aided dosing is hoped to reduce the number of medication-associated errors made,⁶² not everyone has embraced this implementation.⁶³

Personal Assistants

As computational devices have grown smaller, their potential applications and markets have grown larger. Nothing illustrates this more than the field of the PDA. Not even widely known as a concept a few years ago, now many people have computing devices to manage appointments, keep track of telephone numbers, document business expenses, send or receive facsimile information, process documents, or perform any number of tasks once reserved for desktop or larger computers. This growth has even undergone its own transformation, as evidenced by the recent increase in the number of hybrid devices that combine the functions of cellular devices with those of the traditional PDA and even digital cameras. These have gained wider acceptance and are seen as a major direction of growth for the computer industry for the coming years. For physicians, these devices may be used to keep track of hospitalized patients, record notes to be placed in a patient's records, enhance resident education,⁶⁴ or to access drug dosing or other information while away from traditional paper sources.⁶⁵

Patient Care

Computers are becoming a more common part of everyday patient care. Microprocessors are found in everything from the electronic thermometer used by the nurse to cardiac monitors, from terminals for order entry,⁶⁶ laboratory reports, and graphic summaries of patient status⁶⁷ to voicemail systems. Computers may be used to store and study photographic^68,69 or imaging data to facilitate patient care.⁷⁰ Computer access to information and literature references can have a profound impact on clinical decision-making and health care costs.^71,72 In gynecology, this has included the computer analysis of colposcopy images.⁷³ Patients may use computers to tract their own health⁷⁴ or complete a gynecologic history.⁷⁵ Computers have been used to evaluate the physician–patient interaction⁷⁶ and how patients make health care choices.⁷⁷ There are even examples of computers used as translation devices.⁷⁸

Clinical protocols are especially well suited to computerization, because computers allow customization of the protocol for individual patients. Computerized diagnostic and therapeutic protocols are especially useful for reminding physicians about diseases that are encountered relatively infrequently in clinical practice.⁷⁹ In fact, some studies have purported to show that computerized protocols can measurably improve the quality of patient care.⁸⁰ The best example in gynecologic practice is the management of cervical cytology screening with computer-based protocols to facilitate management and follow-up.

The ability to transmit computer data, voice, and visual information rapidly^81,82 has led to the development of telemedicine. This application of computers and communication technology has become widely applied in obstetrics and gynecology and other fields.^83,84 The technology that allows clinical consultation also opens access to other forms of medical information, resulting in the ability of institutions to be available to even the most remote practitioners.^{85,86,87,88,89}

While the software and computer technology involved is often either transparent or unmodifiable by the end user, virtually all medical imaging is now computer-based. The bedside ultrasonography unit that displays real-time images is a sophisticated computer system that has only a superficial relationship to the cathode ray tube systems of only a few years ago.⁸⁶ The images studied by radiologists are now routinely captured without film, transmitted to remote locations for interpretation, and stored in computer files that can be access from the clinic or bedside.^{87,88,89,90,91}

Information Processing

The “information age” can been a daunting concept⁸⁸ until one realizes that information has always been all around us. Now it may be managed, moved, and organized in ways yet to be designed. Information is a vital part of medicine. Computers are “mind amplifiers” that offer the ability to manage this growing quantity of information in useful ways, changing even the way we view information itself.⁸⁹

Reference Support and Networking

A familiar example of computers in medicine is the use of the computer as a fast and efficient clinical reference source and manager.⁹⁰ Many of these now provide full text transfer in addition to citations. The most common example in the office setting is accessing the medical literature using a “dial-up” or remote database such as MEDLINE.⁹¹ Search interfaces such as Grateful Med and PubMed make this form of access to the National Library of Medicine intuitive and easily mastered. Other examples of computer uses for reference support include tables of normal laboratory values, ultrasonography look-up tables, and prescribing information for medications. In fact, most of the reference materials that physicians commonly use in a clinical setting have been computerized. This text itself is an example. After 70 years in a loose-leaf format, the compact disk read-only memory (CD-ROM)-based edition was introduced in 1997 and now no new subscriptions are available except in the CD-ROM format.

ACOG was one of the first organizations to maintain its own dial-up database, ACOGNET.⁹² That database contained full-text renditions of virtually all ACOG publications, including technical bulletins, précis, prolog, committee opinions, and more. In addition, ACOGNET had an electronic mail (e-mail) system and various public domain and “shareware” computer programs. This system has been replaced by an extensive presence on the World Wide Web (Internet). The same information and features are included in the ACOG Web site but speed and ability to provide graphics, sound, new forms of navigation, and the creative use of animation have been added. This Web site has a public information side and extensive resources for ACOG members through its members-only side. This site provides the portal to such diverse functions as the posting of profiles for individual practices to the downloading of residence performance reports for the Counsel on Resident Education in Obstetrics and Gynecology in Training examination.

Dial-up databases for searching the medical literature have been available in the clinical setting for quite some time,⁹³ but they are no longer restricted to the watchful eye of the librarian.

Physicians now routinely use databases from home, the office, or the airport. In addition to providing easy access to current articles in the medical literature, some commercial providers also allow access to a wide range of articles from nonmedical publications. Internet search assistants, also known as gophers, have also become available to assist in medical information retrieval.⁹⁴

Personal computers equipped with CD-ROM devices can take advantage of several commercial vendors who supply CD-ROM versions of the complete (English and foreign) MEDLINE database from 1966 through the present. There are also specialized databases, such as Silver Platter's CANCER-CD, which contains a subset of the literature focusing on a specific subject.⁹⁵ The Physician's Desk Reference is available in a CD-ROM version or as a PDA. Medical CD-ROM applications that cover the current literature are usually updated quarterly or annually. The wide availability of high-speed Internet connections has supplanted these services and subscriptions for many, but they still offer access for those who travel or have slower connection rates.

The most significant change in the application of computers in obstetrics and gynecology is their use for communications within the Internet.⁹⁶ The Internet provides a high-speed communications path to computers located virtually anywhere in the world.^97,98 The possibilities of individual physicians and hospitals⁹⁹ are limited only by imagination. An extended discussion of the possibilities offered by Internet access goes beyond the confines of this chapter, although excellent reviews may be readily found elsewhere.^100,101,102

Electronic Mail

Once the province of large institutions and the business community, electronic mail (e-mail) is now the domain of grandmothers and school children. E-mail options are offered by large computer services, via the Internet, or as a part of simple office networking software. By way of e-mail, memoranda, personal or business letters, reprints, patient summaries, or requests for information may be sent and received more quickly than even a facsimile transmission. Even formal or informal consultations now take place through the vehicle of e-mail.¹⁰¹

Variants of e-mail include mailing lists, news groups, and bulletin board systems. Mailing lists and newsgroups provide a structured and formal method of information interchange, but there is a significant difference between the two methods. A mailing list discussion comes directly to your individual electronic mailbox. An example of this is the electronic mailing list for e-mail copies of the table of contents or full text versions of The Centers for Disease Control and Prevention's publications, including Morbidity and Mortality Weekly Report. The messages that form discussions in newsgroups are sent only to the newsgroup administrator, who then sends them to Internet newsgroup system sites (not individual subscribers). You then read the messages in the newsgroup at a particular system site just as you would walk down the hall to read the messages posted on a bulletin board. In fact, the origin of newsgroups was as a bulletin board service in which messages could be posted for all to see. These systems can be very useful of keeping geographically separated members of a group connected or for the dissemination of information quickly.¹⁰²

Databasing

Database management systems are computer programs used for storage, retrieval, and analysis of blocks of information. These programs have the capacity to manage large volumes of data with multiple cross-indexes. Most database programs can also exchange data with other programs, such as word processors or spreadsheets. In a gynecologic practice, they are useful in a variety of administrative tasks, including patient files, inventory lists, reference indexes, and more.¹⁰³ An example of this type of application in women's health care is the use of databases to establish mammography registries.¹⁰⁴

Computers have long been synonymous with the high-tech world of research, to the point of being the cinematic staple of any laboratory or “mad scientist.” Computers have been used to provide new insight into many aspects of medicine that would otherwise be impossible to study.¹⁰⁵ Computer databases are used to keep track of DNA information¹⁰⁶ or interrogate the human genome project.¹⁰⁷ Gynecologic applications have included basic investigations into uterine physiology,^{108,109,110,111,112} fetal behavior,¹⁰⁹ and other areas.¹¹⁰

Patient

Computer technology has been applied to patient education in two broad ways. The first methods used a computer to generate all the text and graphics displayed on the computer screen, but a substantial amount of direct patient interaction with the computer keyboard was usually required. Nevertheless, despite this drawback, this approach has been successfully used for various patient education projects.^{111,112,113,114,115} Several commercial programs of this type are available for use in office and hospital settings.¹¹² Among these are a number of programs applicable to gynecology,¹¹³ including a series of programs designed to provide informed consent for surgical procedures. A prime example of this type of computer application was the ACOG's Patient Advice and Consent Encounter informed consent program that was offered for several years but was withdrawn from sale in 2000.

A second and much more powerful approach to computer-aided patient instruction is to use a computer in conjunction with another device. The most common example of this is the combination of a computer with a videotape, videodisc,¹¹⁴ CD-ROM, or digital video disk (DVD) system. With this method, the visual quality of the presentations can be excellent, and existing films and videotapes can be easily incorporated into the lessons. In addition, patient interaction with the computer can be greatly simplified. Patients can select a topic from a list that appears on the computer screen. They can then use the computer to control the speed and the progress of the presentation. This simplicity of operation along with the high quality of the visual presentations make the combined approach the logical choice for most private practice settings.

Despite the potential benefits of computers in patient education, this technology has not been widely implemented in the private sector, partly because of physician's concern regarding the willingness of patients to accept the technology. A more important factor was the lack of supporting software from commercial vendors. These are now beginning to come on the scene in the form of CD-ROM products for the home, Internet services, commercial online service providers, and even video games.¹¹⁵ In contrast to this shortage in patient education materials, the availability of software for the education of health professionals is rapidly increasing.

Physician and Staff

Computer-aided instruction (CAI) for health professionals is gaining in popularity, based in great measure on the wide availability of simple, inexpensive tools.^116,117,118 The first medical CAI systems were showcase projects developed by and for academic centers. They were usually large, expensive, and limited in scope.¹¹⁷ However, several effective educational systems were developed within academic departments of obstetrics and gynecology. At the University of Arkansas, Jelovsek and associates developed PC-CAI, a microcomputer-based question and answer system for teaching obstetrics and gynecology.¹¹⁸ Initially designed to help house staff prepare for the Committee on Resident Education in Obstetrics and Gynecology (CREOG) examination, PC-CAI was expanded into a more generalized teaching aid for students, nurses, and residents. Databanks of questions compiled to help with student and resident education and to help prepare for examinations of the CREOG type are now available from a number of sources.

Haken and associates at the University of Michigan used a computer conferencing system that became an integral part of their student clerkship in obstetrics and gynecology.¹¹⁹ Using personal computers and terminals connected to the university mainframe computer, students could discuss selected topics with various faculty members, including the chairman. Similar systems are still in use in some departments.¹²⁰ Studies indicate that computer-based education compares favorably with traditional methods.^121,122 With simpler computer systems have come a wide variety of clinical simulations^{123,124,125,126} and other computer teaching strategies that are gaining acceptance into mainstream medical education.^{124,125,126,127,128,129,130} These have gone as far as the use of virtual reality to facilitate training in surgical fields.^{125,126,127,128}

Today, a growing number of programs are being produced for the continuing medical education (CME) of practicing physicians. Most of these newer programs are designed to be used in a physician's office with high-speed Internet connections. Many take advantage of the multimedia capabilities of fast personal computers and inexpensive CD-ROM technologies.^126,127,128 Some of these programs have been marketed as commercial products, and others have been distributed by pharmaceutical firms as a free service. An excellent example of CME opportunities in obstetrics and gynecology is the ACOG CD-ROM-based programs including colposcopy, ultrasonography, and contraception. Summaries of national meetings, including audio and video recordings of key presentations, are now commonly available from either meeting organizers or commercial sponsors. Examples include synopses of the ACOG annual clinical meeting that have been distributed for the past several years.

As with patient education systems, these programs are most effective when audiovisual capabilities of the computer are fully used. Pictures and diagrams are especially important for the most common CME subjects in gynecology: colposcopy, ultrasonography, cystourethroscopy, and new surgical procedures. Instruction in these subjects clearly requires the effective use of photographs, illustrations, and moving images. With a computer–video combination, any one of the more than thousands of graphic images stored on a CD-ROM, or the millions available on the Internet, can be selected and displayed on the screen in a fraction of a second.¹²⁷ The same video library used for CAI can also serve as an encyclopedic reference source in a physician's office. Unfortunately, the expense of producing videodisc limited the widespread use of that technology; however, this is not so for the CD-ROM and DVD. More and more of this technology is being ported to the Internet, which allows access to a constantly updated body of information.¹²⁸

One paradox of computerization has surfaced: as computers enter the realm of clinical practice, they have the potential to displace some of the more traditional opportunities for student and resident education.^129,130 Computer-based education also requires exposure, access, and comfort with computer technology, which is not always present.^131,132 Like so many aspects of medicine at the dawn of this century, medical education will have to adapt, although it is certain that the future of that educational process will include computers^133,134,135 and the Internet.^134,135,136

One additional aspect of physician education that has evolved with escalating computer capabilities and the widening availability of the Internet is the tracking of CME credits. Recently, ACOG has introduced online tracking of ACOG cognates earned by fellows.¹³⁵ As one would expect, this tracks only those cognates reported to ACOG, but most ACOG-sponsored programs now report cognates earned directly to the central database, bypassing the old system of paper records.

Administration

Word processing, database management, and scheduling are the three classical nonfinancial applications of computers in practice management. For each of these applications, there is a wide assortment of commercially available programs suitable for use in a gynecologic office setting. Of newer and of potentially greater impact is the use of computers to identify referral requirements, formulary limitations, and other important aspects of managed-care networks.

The most obvious medical application of database programs is the computerization of medical records.^136,137

Paperless Records and Patient Management

The use of a paperless record is a goal that has long-been sought but seldom achieved.^138,139 Despite the universal use of computers in hospitals, implementation of a computerized medical record has been disappointing,¹⁴⁰ accounting for a small fraction of medical records.¹⁴¹ The process of developing a computerized record is not simple and requires extensive advance preparation to insure efficiency and privacy.^{142,143,144,145} Despite this, direct access to patient information, such as laboratory reports and other data, even from patients' rooms is becoming common.¹⁴³

One of the earliest attempts at automation of the outpatient record is the COSTAR project (computer-stored ambulatory record), which was originally developed more than 15 years ago at Massachusetts General Hospital.¹⁴⁴ Although the COSTAR system has been used in various clinical settings, there are few examples of it in the specialty of obstetrics and gynecology.¹⁴⁵ Another example of a major computerized medical record system is the program developed at Duke University known as the medical record (TMR).¹⁴⁶ This system was successfully implemented in the Duke University gynecology clinic and has reportedly been well-received by physicians and staff.^147,148 However, although COSTAR and TMR have worked well in a few academic centers, neither system has been adequately tested in an individual or small group practice setting.

A few years ago, two obstetrician–gynecologists in New York developed a physician's workstation to automate the scheduling, billing, and medical record needs of the private practice.¹⁴⁹ One of the more interesting aspects of the system was the inclusion of medical record alerts. Based on laboratory, clinical, and historical findings, the program reminds the physician of the need for specific follow-up tests. Another important feature was that the physicians could connect to their office computer remotely while they were at home or in the hospital. Although this system seemed to work well for these two physicians, the program never gained wide acceptance as a commercial product. A recently reported system has used a computer-based record to improve the clinical management of HIV, although this was a narrow and somewhat specialized application.¹⁵⁰ There have been some small-scale successes in which a computerized medical record appears to have made a difference,¹⁵¹ but these have been few. What has become apparent from these attempts is the extreme amount of time, effort, and expense that a computer-based medical records system entails.¹⁵²

The possibility of patient-carried medical records in the form of smart cards has been raised. These are plastic identification cards that have an electronic chip similar to the smart cards introduced by some credit card companies. The chip on these cards retains critical information in computer-readable digital forms. Used like a credit card, these devices could contain the contents of the patient's medical record, recent laboratory and imaging studies, medication history, and other pertinent information. The role that these may have in a future of paperless records is being debated^153,154 and is far from clear, with issues including access and privacy still to be resolved.¹⁵⁵

There has been a proliferation of clinical computing projects in the gynecologic subspecialty of reproductive endocrinology.¹⁵⁶ Reproductive Endocrinology Medical Information System (REMIS) was an ambitious project developed at Johns Hopkins University.¹⁵⁷ In addition to research support and medical record functions, this system also provided for patient scheduling. Another example of a comprehensive system is VERGYNIA,¹⁵⁸ a microcomputer program design specifically for an infertility clinic. VERGYNIA is a computerized medical record system that consolidates the laboratory, clinical, and historic data needed for the evaluation and management of infertile couples. Unlike the first two examples, most of the more recent reproductive endocrinology programs are smaller, microcomputer-based systems that focus on specific areas, such as postcoital testing¹⁵⁹ and in vitro fertilization.¹⁶⁰

Although computer applications in gynecologic oncology are fewer and more limited in scope, several early and successful computerization projects have been reported,¹⁶¹ including small computerized tumor registries.¹⁶² Others are complex programs used in the planning of treatments for gynecologic oncology patients. For instance, in Germany, Englmeir and associates developed a program that generates three-dimensional reconstructions of pelvic anatomy depicting the location, volume, and radiation dosimetry pattern for individual patients who have gynecologic malignancies.¹⁶³

A subject more relevant to office gynecology is the management of cervical cytology.¹⁶⁴ Smith and associates in England developed the best-known program of this type.¹⁶⁵ This system generates letters that tell patients the results of their Papanicolaou (Pap) smear tests and inform patients of the computer's follow-up recommendations. If a patient does not return to the clinic as recommended, the system automatically sends the appropriate follow-up letter. In addition to developing and implementing the system, the authors published a series of articles assessing the effectiveness of the system and analyzing the reasons for patient noncompliance.¹⁶⁶ The results of their analysis are pertinent to manual and computerized systems for patient follow-up.

Discharge Summaries

Although completely automated medical records are not common and almost completely absent from most private practice settings, DBMS can be used for other less comprehensive medical record applications.¹⁶⁷ For instance, a simple computer file containing patient identification data along with a few important dates (e.g., dates of last Pap smear) can be used to generate appointment reminder letters. Adding a few diagnostic codes to the same database can provide useful practice statistics, letters to referring physicians, or computerized discharge summaries^168,169 (see Fig. 2). The number of additional practical applications of DBMS in a physician's office is almost limitless.

Case Lists and Residency Documentation

The task of collecting, organizing, and reporting case experience for individual certification or for the certification of residency programs has become almost exclusively the province of computerized data systems. The American Board of Obstetrics and Gynecology makes available software for personal case list compilation that will run on PC platforms but not on the Macintosh (at this time).¹⁷⁰ Although the case lists required for the oral board examination are still submitted as a paper submission, the only practical way of compiling the list is through the use of this or similar software.

Less standardized are packages that have been used for maintaining the records necessary for the process of residency review and certification, although many simple database management systems have been used for many aspects of the record-keeping needed. Beginning in July 2003, The Accreditation Council for Graduate Medical Education mandated that all residency programs in obstetrics and gynecology use an Internet-based reporting system. This system requires that each case is entered individually, with the Web-based system generating the summary statistics that used to be the sole information reported. The transition to this system has not been without problems and the adoption has not been universally enthusiastic, although noncompliance is not an option.

A major nonfinancial administrative application is computerization of scheduling appointments and procedures. A variety of these programs are now available for use in a physician's office, allowing automation of patient appointments and staff scheduling. Although computerized scheduling systems are more efficient than manual methods, they are often unacceptable in a private practice setting. The problem with computerized scheduling system is inflexibility. Older examples of these programs did not adapt well to group practices in which individual physicians vary in their scheduling patterns, although newer versions allow a greater number of choices. Nevertheless, in solo practices and in groups with relatively uniform scheduling patterns, computerized scheduling can be cost-beneficial.

Letters and Follow-up

Word processors are clearly one of the most useful applications of computers in a medical office. Word processing programs allow increased speed, easier error correction, and the ability to check for proper spelling and grammar. Furthermore, word processors can be linked to database programs to generate form letters such as patient appointment reminders. The cost-effectiveness of form letters such as these computer-generated reminders has been demonstrated in various clinical settings.^171,172 These letters are especially useful in a gynecologic practice to remind patients about postoperative follow-up examinations and yearly checkups. One study has even looked at the usefulness of computer-generated telephone calls to improve patient compliance with further appointments.¹⁷³

The automation of the financial aspects of a medical practice is an appealing but potentially dangerous application of computers in a physician's office. When they work well, practice management programs are clearly cost-effective and can save physicians time and money. However, they are also among the most complex and expensive programs used in a private practice setting. In addition, they are often difficult to implement and may not be readily accepted by the office staff. Therefore, all decisions regarding selection and implementation of a practice management system must be carefully considered.

Any practice management package considered for use in a gynecology practice must meet a few basic requirements. First, it must be able to maintain a sufficient number of individual patient data files containing all essential identification and insurance information. Second, it should be able to process claims and generate statements based on a file of individual patient encounters. Finally, based on these and other files, the system must be able to maintain a balanced general ledger and generate various reports. These reports must include older accounts receivable and basic practice statistics.

Most practice management packages offer a number of supplemental features that can be added to the system. The most common of these add-on accessories are patient scheduling and employee payroll programs. Accounts payable and inventory management programs are also frequently offered.

Because most office computer systems were originally designed for nongynecologic practices, they often are not well suited to the needs of our specialty. Consequently, many gynecologists who have attempted to automate their practices have had disappointing, and occasionally disastrous, results. To minimize the risks of such disasters, it is advisable to consider only those programs that have already been successfully implemented in an obstetrics and gynecology office setting. Until quality programs specifically designed for our specialty become available, it is likely that most gynecologists will continue to depend on manual accounting systems for their office practice.

As the administrative demands of clinical practice increase, computerization of diagnostic and therapeutic codes^174,175 is becoming increasingly important. Various programs have been developed to help medical personnel translate diagnoses and procedures into standardized codes such as ICD-9 and CPT-4. Programs of this nature are becoming increasingly more important as diagnosis-related groups and other new coding systems are imposed on practicing physicians.

Some third-party payers have made available online interfaces that allow the physician's office to verify coverage or eligibility. These systems have not been widely implemented, and the enactment of extensive protections for patient's privacy will most likely result in the abandonment of the few systems that do exist.

As medicine has become more of a competitive business, computers have taken on a role in practice promotion. This has ranged from the development of practice advertising, newsletters, direct mail information, and even computer-generated telephone follow-ups.¹⁷⁶ Speaker support and desktop publishing applications lead the way in more traditional forms of support for practice development and marketing, although the ability to use accounting software to develop managed care proposals, cut overhead costs, and identify the demographics of potential patient populations are gaining importance.

A growing number of practices have elected to have a presence on the Internet with Web pages that promote their practice, provide general medical information, and can even allow patient (with appropriate password protection) to make appointments. The ACOG, through its participation in the Medem consortium, offers the ability to construct Web pages for practice promotion.¹⁷⁷ ACOG itself offers information about practices to physicians and patients through its public and members-only Web site.¹⁷⁸

Project Management

Project management is an often-overlooked application of computer technology that may be applied to projects as diverse as the development of a managed care proposal or a research project. This type of software is used to develop critical path (Gant) charts that help manage the resources and time necessary for a given project or group of tasks. To use these programs, a project is broken down into smaller steps with the times, resources, and relations to other elements indicated in a graphical interface. The program will then determine the time needed, the rate-limiting steps, conflicts with resources, and expected milestones. These programs are more familiar in the business world but may find wider use in medicine in the next few years.

10BaseT	A method of distributing ethernet data short distances over ordinary telephone lines.
Address	The physical, or conceptional, location of information within the computer, usually used to refer to memory locations. In Internet parlance, the string of information (human or machine readable) that specifies the location of the information of interest and the computer on which it is located.
ADSL	Asymmetric Digital Subscriber Line. A method of transmitting data at high speeds over telephone lines. In this system the speeds of transmission in one direction or the other may differ.
Alias	A name or placeholder for a file, application, destination, or grouping of information. A special recipient name for a group of Internet addresses.
Anonymous FTP	Computer site set to allow public retrieval of files using the login “anonymous.”
Applet	A small computer program, written in the Java programming language, that is downloaded and run under the auspices of an Internet browser program.
Application	A group of instructions that tell the computer how to accomplish a task. This is usually a relatively complex set of instructions that handle a variety of related tasks necessary to accomplish an overall type of task, such as word processing, making a graph, or playing music.
Archie	An information retrieval system for anonymous FTP sites.
Archive	A set of one or more files that have been compressed to save space or speed up transmission over the Internet. Many of these files have names that end in .zip or .sit depending on the compression program used to create the file.
ASCII	American Standard Code for Information Interchange. A computer code for expressing numerals, letters of the alphabet, and other symbols based on eight bits of binary code.
ASP	Either Active Server Page or Application Service Provider. Active Server Page is a scripting environment for Microsoft Internet Information Server in which you can combine HTML, scripts, and reusable ActiveX server components to create dynamic Web pages. An Application Service Provider is an Internet-based provider of application programs that reside on the provider's computer but are used by (loaned to) the Internet user or subscriber. In this service, the data may reside on your computer, but the application that uses the data remains on the server.
Attachment	One or more files that are sent along with an electronic mail message.
Audio board/sound card	Some computers require the addition of an additional circuit board to play monophonic or stereophonic sounds. With such a card and a compact disc player, the computer may play music, or utilize sounds embedded within software programs. Many computers require a sound card to play music or transmit voice over the Internet.
Back door	A secret way into a computer or computer program that bypasses the normal security procedures.
Backbone	The basic communications link of a network.
Bandwidth	A measure of the amount of information that may be transmitted at a given time. Applied to the Internet in general, but may be applied to any method of information transmission. Often used in off-hand comments about the content of information, such as “It was a waste of bandwidth,” to indicate wasteful or frivolous information.
Baud	This term, introduced in 1931 and named for the French inventor J. M. E. Baudot, is a measure of the speed of transmission of information. Originally applied to Teletype information, it is roughly equal to one character per second.
BBS	Bulletin Board System. Electronic bulletins board where messages may be read or posted for others to see.
Binary	Based on two alternatives, such as mathematical base 2. In this base, only two digits represent all numbers: 1 and 0. Like the base 10 that we use every day, position relative to the rightmost digit determines the exponential value of each digit. When summed the final valued is reached. In base 10 (B10) the expression 123 is equivalent to 1 times 102, plus 2 times 101, plus 3 times 100. Since 102 = 100, 101 = 10, and 100 = 1, this gives us 100 + 20 + 3 = 123. In base 2 the same principle applies except that the base number used for each place is 2. Therefore, 10112 = 1 times 23, plus 0 times 22, plus 1 times 21, plus 1 times 20 or 8 + 0 + 2 + 1 = 1110.
Bit	The smallest unit of information. A unit of information that may have two states (e.g., 1 or 0). This may represent any information that has two mutually exclusive conditions, such as true or false, on or off, light or dark, etc. In a binary string, it represents one digit. In computing, a bit is a single 1 or 0 stored in the computer.
Bookmark	An Internet address (URL) that is stored in a folder for future reference. In Netscape the file is called the bookmark file, while Internet Explorer calls the file favorites.
Bounce or bounce back	To have an electronic mail message returned as undeliverable. This may happen if you have a bad address or if the receiving party cannot receive mail at that time (e.g., server is off-line).
Browser	A computer program that acts as an intermediary or agent that requests and interprets information sent over the Internet.
Buss	The electronic highway that the computer uses to send information back and forth between the central processor, memory locations, special chips that perform special tasks such as a video generator, or the outside world by way of ports.
Byte	A collection of bits, usually in multiples of two, such as 4, 8, 16, or 32. This represents the width (in bits) of a computer “word.” The larger the byte a computer can use, the more information that may be contained in a single word. A byte that is four bits wide can contain only 16 (24) possible combinations of 1's and 0's. By contrast, a 32-bit byte can contain over 4 million combinations (232).
Channel or chat room	One of several terms used for an area where Internet users may exchange live text messages. Channels and chat rooms often have themes that provide a common thread or topic of conversation. Some channels or chat rooms have a monitor to keep order, some do not.
Client	A computer that uses the services of another computer (a server).
Clock speed	A timing “clock” coordinates all of the activities of the computer. All activities take place as discrete steps that are kept in cadence by this clock. As a result, the faster the clock speed, the more instructions or activities the computer can accomplish in a give amount of time. Because of the amount of data transferred and manipulated during and Internet session, a computer with a fast clock speed is required.
Cookies	A small file left on your computer (in the hard drive) that saves information about you and your interaction with the distant computer Web site. This information may contain when you last visited, your shirt size, type of computer you use, or your preference in books. The next time you visit that Web site, it can retrieve the cookie and use the information to customize its interaction with you.
CPU	Central Processing Unit. This is the “thinker” that makes the computer function. This is the chip that interprets the software instructions, performs operation such as addition and subtraction, stores and requests information from memory, and makes logical decisions. It is this branching to various parts of a computer program based on conditions that could not be known at the time the program was written that makes computers so powerful. Like clock speed, the more powerful the CPU, the faster and easier Internet travel becomes.
Cursor	An indicator (flashing box, line, underline, arrow, or other image) displayed on the computer monitor that tells the user where the next action will take place.
Daemon	An automatic utility program that runs in the background of a computer. Often used to respond to requests for information or to handle incoming mail.
Digest	A collection of messages about a specific topic prepared by a mailing list moderator.
Disintermediation	The ability to directly connect two parties without the use of an intermediary. Examples include directly entering an order into a seller's computer system without a sales agent or distributor, and the obtaining information directly from a source that was previously available only through an intermediate agent.
Document	A body of data that may be interpreted by an application. This may be information about the look and content of a letter, how to draw a picture or graph on the screen, the contents of a spreadsheet, or any other body of data that an application may need to carry out its task. Generally these data are specific to a set of circumstances that the user has specified and are not required for the normal operation of the application. (See Resource.)
Domain name	Name of a computer system that is registered with the Internet. Can be made up of subdomains such as geographic or organizational subdomains.
Download	To obtain a file of data or a program from a remote computer.
DSL	Digital Subscriber Line. A high-speed form of telephone connection that is becoming more common in residential areas. Connections must be within a maximal limit of the telephone company's switching system (generally 3 miles). These connections require a special form of modem.
Dynamic rerouting	Ability of a network to direct communications around a damaged connection to still reach the intended recipient.
E-mail	Electronic mail.
Emoticons	Icons for indicating emotions (see Chapter 2, Table 2.7).
EPROM	Erasable programmable read-only memory. A type of ROM that may be altered by the user or machine but that retains the information when the power is removed. This is useful for storing some types of information, such as start-up preferences, security passwords, etc.
Ethernet	A fast local network originally developed by Xerox Corporation.
Eudora	A mail-handling program for either Windows or Macintosh computers.
FAQ	Frequently asked question(s).
File	Like a document, this is a collection of data. The term is less specific and may apply to a document, application, or other collection of related data.
Film recorder	Similar to a printer, this device uses instructions passed from the computer to draw information onto film using a very narrow beam of light, passed through one of three primary filters. Just as a printer “draws” a letter on the paper, film printers “draw” information onto film, which may then be developed to reveal the image.
Firewall	A combination of hardware and software used to keep unauthorized users from accessing part or all of a computer's files or connections.
Firewire	A proprietary (Macintosh) connection port for high-speed transmission of digital video data.
Flame	To post angry or insulting messages. This may lead to a flame war, or (fruitless) exchange.
Forum	Same as a Newsgroup.
FreeNet	A computer network that brings together the resources of a community or campus and is available free of charge.
Freeware	Software distributed at no cost. It cannot be sold or incorporated into other software, but may be freely distributed.
FTP	File Transfer Protocol. A set of specifications that support Internet file transfer.
Gateway	Computer system that acts as a point of access that allows information to move back and forth between networks. Often used when the networks involved use different protocols.
GIF	Graphics Interchange Format. A form of graphics file compression developed by CompuServe to be used for file transmission over the Web. These files are generally larger than files using the JPEG format.
Gigabyte	One billion bytes of data.
Gopher	A way of organizing and categorizing certain types of information on the Internet.
Graphics tablet	A type of information input device that uses a pen or other cursor devices on a special surface or tablet to draw, write, or select options. This type of input device is very commonly used for graphic arts and design work.
GUI	Graphic User Interface. The “desktop” metaphor used by Macintosh computers and the Windows series of operating systems. These interfaces use icons such as folders and sheets of paper to take the place of directories and data documents to facilitate use by those not familiar with the details of computer structure or function.
Hacker	A person that attempts, for fun or other purposes, to use unauthorized means to enter and use other computers. Generally applied to computer entry via the Internet.
Hardware	Physical computer equipment.
Header	Information placed at the start of an electronic mail message that assists with routing and the display of the message.
Hit(s)	Visit(s) to a Web page over a period of time.
Home page	A Web page about a person or organization. Often used to mean the first screen of information that someone sees when accessing a Web site or opening a browser program.
Host	A synonym for any computer connected to the Internet, generally at a remote location.
HTML	Hypertext Markup Language. A computer language used to transmit information about the display of graphics, text, music, and other information. The language allows commands to be embedded that instruct the computer on what information is to be displayed, in what manner, and where that information may be found. The language allows references to information to take the place of the information itself, resulting in smaller files and faster information transfer. Most Web browsers interpret HTML instructions as part of the process of creating the Web page we see.
HTTP/HTTPS	HyperText Transfer Protocol. The way the World Wide Web transfers pages over the Internet. The additional “S” indicates an encrypted or secure transmission protocol.
Hyperlink	A word or phrase displayed in an Internet browser (or elsewhere) that will take the user to related information. In text, these are most often displayed in a different color, underlined, or both. When a graphic or icon is used as the starting point, the user's cursor will change to a hand when passed over the active link. In either case, a mouse click on the link will take the user to the related material.
Hypertext	Text that contains embedded links to other data.
Initialization string	A series of characters that is sent as commands to a modem that establishes the settings to be used. The exact commands required will be contained in the modem's user manual.
Internet	The name for a group of worldwide computer-based information resources connected together.
InterNIC	Internet Network Information Center. A central repository of information about the Internet and site where domain names may be registered. (http://www.internic.net)
I/O device	Input/output device, or a device that allows communications between the user and the computer. It may take many forms: a keyboard, display screen, printer, scanner, modem, film recorder, or mass storage device such as a hard, floppy, or compact disc drive. Some of these communicate in only one direction, while others are capable of two-way communication. Collectively, many of these devices are referred to as peripheral devices. The most common I/O devices involved in using the Internet are modems or network interface cards.
ISDN	Integrated Services Digital Network. A very high-speed connection (usually a dedicated telephone line) used to link computers to the Internet or to connect one computer to another.
ISP	Internet Service Provider. A third-party provider that supplies access and temporary Internet addresses to users by way of dial-up modem connections. In many cases, the provider also supplies additional services such as e-mail accounts, databases, chat rooms, etc.
Java	A programming language that allows small applications to be transmitted across the Internet and run independently of the computer platform used. These programs generally perform small tasks related to the display of information in Web browsers.
Jazz disk	A trade-named removable disk based on technology introduced by Iomega, which can store approximately 1 gigabyte of information. The term, like Kleenex and Xerox, has become generalized to refer to high-capacity small diskettes.
Joystick	A pointing device based on the two-dimensional motions of a control stick. Common in the early days of computing and in game playing, now relegated mainly to the world of video games.
JPEG	Joint Photographic Expert Group. Compression standard used to format pictorial information. Files formatted using this standard usually have names that end in .jpg or .jpeg. Usually pronounced “JAY-peg.”
Jughead	An information retrieval system for a specific Gopher site.
Keystroke logger	A program that automatically keeps a file of everything that is typed from the keyboard.
Link	A hypertext pointer to another file or Web site that may be invoked by pointing and clicking on the appropriate portion of the displayed Web page. The term also refers to the text-based reference to the URL provided in the Web page instructions themselves.
Listserv	Listserver. The most common computerized mailing list administration program.
Login ID	Unique identifying character string assigned to a user of a computer system.
Luddite	A person who believes that the progress brought by machines is dangerous to the public good.
Lurk or lurking	Listening in on a mailing list or newsgroup discussion without replying.
Lynx	A text-based Web browser program.
Mail server	A computer that provides electronic mail services.
Mailbot	A computer program that automatically sends or answers electronic mail.
Mailing list	A collection of Internet addresses that facilitates an electronic discussion group.
Mass storage device	One of several types of devices that store large amounts of data in the form of files. Most common are hard disk and floppy disk drives. Compact disk players that can read computer files stored on CD-ROM disks also come under this heading. Internet surfing requires a large amount of storage space for both intermediate files used by the Web browser to display each page and by the audio, video, and picture files often transferred and stored by the user.
Megabyte	One million bytes.
Memory	A nonspecific term for the area in which information is stored. The term may be applied to the working memory of the computer, such as RAM, ROM, etc., or to mass storage devices such as disk drives.
MIDI	Musical Instrument Digital Interface. A protocol for transmitting music as a series of commands (notes) rather than as the sounds themselves, allowing the receiving device to play them in their own way. Many electronic instruments can sent or receive MIDI information.
MIME	Multipurpose Internet Mail Extension. A system used to send text, pictures, programs, and other nontext information as a part of electronic mail.
Mirror	One or more computers that share (mirror) the same information so that the load on popular sites may be spread out to improve access speed. In some systems, a mirror site may be selected automatically and the user is unaware of its use; in others, users may choose the mirror site they wish to use.
Modem	Derived from the terms “modulate” and “demodulate,” a modem uses telephone or other communications routes to transmit data. The speed and protocol by which this is done varies, but shares the common feature of converting digital information into a varying tone that may be carried by the communications path and interpreted by the receiving modem, which converts the tone back into digital information.
Mosaic	A Windows-based Web browser program that was the predecessor of most of the advanced browsers in use today.
Mouse	A type of pointing device that moves on the physical desktop to move a cursor on the computer screen. The mouse usually has one or more buttons or switches with which to indicate choices.
MP3	Motion Picture Experts Group-1, Audio Layer-3. A format for compressing sound into small computer files.
MPEG	Motion Picture Experts Group. A standard (now in its fourth iteration) for how video information is compressed and transmitted.
Multimedia	An overused term for anything that uses more than one media, such as sound, images, movies, and the like. The term is not specific and may be applied to almost any type of software product.
Netscape	A Web browser program available for both Macintosh and PC (IBM compatible) computers.
Network	Two or more computers connected together so that information can move between them.
Newbie	A newcomer to the Internet, just a step up from clueless newbie.
Newsgroup	A collecting site for messages about a specific theme.
Newsreaders	Programs used to access a newsgroup, such as rn, tn, nn, and tin.
Node	A computer (host or server) on the Internet.
OCR	Optical Character Reader. A type of scanner and software that allow a printed page to be “read” into the computer and interpreted as a string of characters rather than an image.
Packet	A chunk of information traveling as a bundle over the Internet. The packet contains information about its origin and destination, file type and size, and additional information about confirmation of receipt, etc.
Parallel port	A pathway for information transfer in which the data are moved as a byte or word over a series of wires that simultaneously have a sequence of 1s and 0s.
Password	String of characters secretly chosen to verify that you are the valid user connected with a specific user ID.
PCMCIA/PCI	Personal Computer Memory Card International Association/ Peripheral Component Interconnect. First developed as a standard for add-on memory for portable and palm-top computers, this now refers to a standard that allows chip-based peripheral components to be plugged directly into a special port to provide special functions such as fax, modems, or memory. These are mainly found on newer portable machines.
PDA	Personal Digital Assistant. A palm-top computer or other microprocessor-based hand-held devices that perform multiple functions. As cell phone technology evolves, these devices may join this group.
PDF	Portable Document Format. This format is used to contain complex documents with graphs, images, and special text that cannot be presented easily through the typical Web browser. The creator of this file format, Adobe Systems, offers a free viewer (Adobe Acrobat Reader) to view any PDF file. There are versions for most operating systems.
PIM	Personal Information Manager. A palm-top computer or Internet-based system of organizing appointments, reminders, names, addresses, and other similar information. Information may be displayed in a number of formats with customized reminders. Internet-based systems may be configured to automatically seek information of this type to be added to your personal files, thus acting as a (partially) intelligent agent.
Pixel	Picture element. The smallest unit used to make a picture on the monitor screen or printer output. The smaller the pixel, the more detailed the picture; the more pixels, the larger the image.
Plug-in	A small computer program that is added to another (usually your browser program) that adds special functionality or a special type of information such as music or video.
Pointing device	Any one of several types of devices used to move a cursor on the computer display. Common types are the mouse, track ball, trackpad, joystick, or graphics tablet.
POP	Point of Presence. Literally, a connection to the Internet. Generally refers to an Internet service provider (ISP) that provides access to the Internet by temporarily assigning an Internet address from a group owned by the provider.
Port	A pathway in and out of the physical box that contains the computer. This path may transfer raw information, or information that has already been processed into a different form, such as a telephone or video signal.
PPP	Point-to-Point Protocol. A protocol that allows the use of someone else's Internet presence on a temporary basis. Internet service providers allow a user to connect to the Internet using this protocol.
Printer	Any device that converts computer information and places it on a printed page. This may be accomplished by the use of a sophisticated typewriter-like device (daisy-wheel printer), a group of small pins that draw letters and images as a set of finely spaced dots (dot-matrix printer), sprayed small droplets of ink (“jet” printers), heated elements that transfer wax (thermal transfer), or drawing the image onto a copier-like drum using a small beam of light (“laser” printers). Speed, quality, and the possibility of color printing vary with the technology used.
Protocol	Agreed-upon rules for communications between devices (generally computers, modems, or fax machines). These include signals that mean “start,” “stop,” “got it,” “send again,” “all done,” etc.
Push technology	Methods that allow information posted on a Web site to be sent automatically to others without waiting for them to request it. This is somewhat analogous to broadcasting the information, but unlike broadcasting, the sender is assured the information will be received.
QuickTime	A video file format widely used on the Internet. Originally developed by Apple Computer but available for all platforms.
RAM	Random Access Memory. This is the memory that may be used by the user and software to store information on a temporary basis. Any location may be addressed at any time. This memory is “volatile” and the information stored there will be lost if the power is lost or if some other information is placed in the same location.
Resource	A set of data, often stored in the same location as the application itself, which is used by the application to accomplish a specific part of its work. Resources may be icons, sounds, images, information, or portions of a dialog directed toward the user. This information is generally only for the use of the application, and may not be addressed or used by the user under normal circumstances.
ROM	Read-Only Memory. This is memory that contains information used by the computer operating system that is independent of the software program that is running. This information is placed there by the computer designers and is permanently place into memory at the time the chips are manufactured. This memory is not lost when the power is turned off, allowing this type of memory to help in the start-up process.
Router	A computer that connects two or more networks.
Scanner	This device is used to convert physical materials into computer renderings. This may be in the form of a picture “copied” from a printed source, the image of a printed page, or through the use of special software, a transcript of the printed page that may be manipulated in a word processing program.
SCSI	Small Computer Serial Interface (“skuzzy”). This is a high-speed pathway for communicating between the computer and special input-output devices, most notably memory storage devices such as hard disks, CD-ROM drives, input devices such as scanners, and the like.
Search engine	A program used to find information on the World Wide Web.
Secure socket	A form of encryption used when transmitting and receiving data.
Serial port	A pathway for information transfer in which the data are moved as a series of 1s and 0s. This is the most common point of connection for a modem.
Server	A general term for any computer that supplies information to other computers. The term may also be applied to the software the facilitates the transfer.
Shareware	Computer programs that are widely distributed on the honor system. You may try the program at no charge, but it is understood that you will send a user or registration fee if you decide to keep and use the program.
SIMM/DIMM	Single In-line Memory Module/Dual In-line Memory Module. A small, single-sided or double-sided circuit card that may be inserted into a computer to provide additional RAM.
SLIP	Serial Line Internet Protocol. A protocol that allows the use of someone else's Internet presence on a temporary basis. Internet service providers allow a user to connect to the Internet using this protocol.
SMTP	Simple Mail Transfer Protocol. The system used to pass mail from one Internet computer to another.
Socket	The logical “port” used by one computer program to connect to another program running on the Internet.
Software	The group of instructions that the computer uses to carry out one or more tasks.
Spam	The act of sending unrequested electronic mail. Generally restricted to mass-mailing types of mail or newsgroup postings. Also, a proprietary meat product from Hormel, Inc.
Surf	To wander around sites on the World Wide Web looking for interesting material.
Tag	The instructions embedded in an HTML file that determine the way the text of the file is displayed. These tags typically take the form <tag> for the beginning of the instruction and </tag> for the end.
TCP/IP	Transmission Control Protocol/Internet Protocol
Telnet	A program used to connect to a remote computer.
Terminal emulation connection	The process that allows your computer screen and keyboard to control a remote computer.
Trackball	A pointing device that moves the computer cursor based on the movements of an upturned ball, somewhat analogous to an overturned mouse.
Trackpad	A pointing device that senses the movement of a finger over its surface.
Trojan horse	A program or message that contains a virus or worm inside.
Upload	To move a file of data or a program to a remote computer.
URL	Uniform Resource Locator. A standardized method for referencing an item on the World Wide Web, including a complete description and its location.
USB	Universal Serial Bus. A high-speed connection found on the newer computers that is used to connect to other devices.
Usenet	User's Network, made up of all machines that receive network newsgroups.
User ID	User identification, synonymous with login ID.
Veronica	An information retrieval system for Gopher sites.
Video card	Many computers require a separate card (electronic circuit board) to produce the video signal sent to the monitor. This card often contains its own dedicated memory (VRAM) to allow more colors, higher resolution, or faster displays.
Virtual memory	A technique that allows space on a hard disk to act as if it were part of the computer's active (RAM) memory.
Virus	Small computer programs that “infect” a computer of files by starting its own operation without the permission or knowledge of the operator. These programs make copies of themselves, allowing them to infect other computers. Viruses vary from those that put a surprise message on the monitor, to those that will erase data or corrupt files. A number of commercial products exist to help identify, remove, or “immunize” against viruses. The use of specialized languages that has made Internet browsers and other tools so powerful (such as Applets and Java Scripts) now opens the possibility of viral transmission across the Internet.
VRML	A language used to build virtual reality pages on the World Wide Web.
WAIS	Wide Area Information Servers. A way of categorizing and organizing certain types of information on the Internet.
War dialer	A program that is used to dial a series of telephone numbers. Often used by hackers to look for computer modems.
WAV file	A format for transmitting sound files. File names generally end with .wav.
Web browser	An information retrieval program for the World Wide Web that can interpret and display hypertext documents.
WebTV	A method of connecting to the Internet using television cables to carry the signal and the user's home television to display the information.
World Wide Web (WWW)	A hypermedia-based system that lets users browse through information stored in different formats.
Worm	A program that is similar to a virus in that it is an uninvited program that “lives” inside your computer and does damage. Worms do damage to computer files by moving through memory (active or storage) destroying what is stored there.
WORM	Write Once, Read Many. One of several types of storage systems, generally in the compact disk format, that allow information to be stored, but cannot be altered once the storage has taken place. This type of storage is attractive for applications where a record of all changes made must be maintained. An example might be patient records, where future additions or alterations must be documented along with the original information.
WYSWYG	“What you see is what you get.” Refers to print and other documents that appear on the computer display in the same way that they will appear when printed to paper or a film recorder.
XML	Extensible Markup Language. A set of extensions to the HTML language that expand functionality.
Zip disk	A trade-named removable disk based on technology introduced by Iomega, which can store approximately 100 megabytes of information. The term, like Kleenex and Xerox, has become generalized to refer to high-capacity small diskettes.

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