Medicine and care are currently faced with an exponential growth in patient expectation and the raw material of cure - information. In concert with many human activities, the primary limitations for future development and delivery are human. How are clinicians and doctors to cope with the growth of information and techniques when the fundamental processes employed have changed little since the time of Hippocrates? Invoking information technology (IT) is the only means available to assemble, sort, and access information on the global scale now required. In addition, the fundamental education and training needs are expanding beyond human ability, and new methods are well overdue. Visualisation, virtual reality, simulation, telepresence and artificial intelligence technologies probably offer the only route to a more rapid and deeper understanding through direct experience. This falls in line with an ancient Chinese proverb:

I hear and I forget
I see and I remember
I do and I understand

Realising a significant improvement requires instant access to information, experience and understanding. Telecommunications now makes this almost universally available to some degree and, with modest developments, will provide remote diagnosis, consultancy, surgery and care. In this paper we present a migrational view of the technologies being developed for deployment and use around the turn of the millennium.

Prologue
The fundamental problem that all professions now face is an exponential growth in almost everything except our own human abilities. Only two centuries ago it was possible to be an expert surgeon, artist and engineer at the same time! Today we are highly specialised (Fig 1), so much so that the truly expert generalist is at best a rarity, at worse an extinct species.

Figure 1: The growth in specialisation

Our plight is entirely dictated by the fundamentally different evolutionary mechanisms of technology and biology. The former is dominated by the step by step discovery of new facts that are used to create newer and in some way better technology - standing on each others shoulders results in continuous feedback and exponential progress. This is augmented by the occasional chance discovery or mutation that gives a sudden revelation and better understanding. The end result is an ongoing optimisation towards the ideal. In contrast, biological systems depend on a much slower process - random mutation and natural selection, to create fit for purpose solutions. Furthermore, mother nature seldom, if ever, optimises!

There is no doubt that our brain of some 10¹¹ neurons is a remarkable machine. Unfortunately, it is one that will see no significant enhancement in the next several thousand years if left to natural development. In dramatic contrast the electronic computer is evolving at a rate that doubles its ability each year or so. This will see desk top computers 10³ times more powerful in ~10 years, 10⁶ times in ~20 years, and possibly 10⁹ times in ~30 years. A sobering thought!

Interestingly, the telecommunications, electronics and IT sectors are the only ones able to sustain such exponential growth as all other human activities most definitely face physical limits that are all to visible. IT and communication can continue the annual doubling process for at least another 30 years on the basis of the technology we already know about and understand.

If we are to cope with increasingly rapid change, promoted by this technological progress, it is necessary to embrace the technology to augment our constrained set of human abilities. We already live in a world of increasingly rapid communication - no escape, a growing mountain of data, customer care and expectation, having to do much more with reduced support and resources. If only:

1. we had access to all the available data
2. all the data was up to date and correct
3. we could easily distil the information from the data
4. we could understand faster
5. we could make the right decision every time
6. we could avoid becoming data rich and information poor

Such a wish list might just be realised within the information society currently being constructed - but with it will come the need to do and achieve more with less human and technological resources. Large, physically centralised organisations will become a thing of the past, as will life long employment in one job! Education and training will become a continual and necessary process with new technologies introducing novel teaching and learning methods.

Why is all of this so exciting and why does it offer such tremendous potential? Most positively, the human race can achieve far more in a shorter time! The standard working lifetime of the previous generation was about 100,000 hours. We can now achieve their output in less than 10,000 hours! The next generation looks set to overtake us in a similar manner - provided we can keep pace with the technology.

Figure 2: The Ages of Mankind

Medicine, care and cure cannot escape this trend! They too will have to adapt and change. For example, as physical distance is negated by telecommunications, experience is made more widely available through information systems, and expertise can be handed on through telepresense. We should not shy away from any of this as it is part of our progression from the hunter, farmer, industrial, information, and soon, to the experience society (Fig 2). Moreover, it is the only means of satisfying the growing customer demand and expectation within the care sector.

Everyone now expects a fix - no one expects to be ill or die!

Communication & IT Magic
In 1956 the cost of a transatlantic telephone call was 2.80/minute - today it is 0.5/minute. Similarly, computers in the home were unthinkable back then and the storage and transport of information was almost wholly conducted by paper. Today, we have a rapidly expanding global network of optical fibre that transports over 65% of the telephone calls world-wide. The first pocket calculator on the market in the early 1970's cost over 80 and had just four arithmetic functions - today calculators with vastly superior functionality are given away with petrol! A low cost electronic wristwatch now has more processing power than a mid-range computer of the 1960's, whilst the personal computer is realising a processing, storage and display abilities for the office and home that completely surpass the mainframe computers of only 10 years ago. This is all a characteristic of an exponential growth in ability, and a correspondent fall in cost - exponentially more for exponentially less!

Figure 3: History and principal trends in cable telecommunications

The scale and significance of the above change is perhaps best exemplified by the reduction in raw material usage (Fig 3). In the UK there is now an installed base of over 3 million km of optical fibre supporting over 90% of the communication needs of a 57 million population. The entire fibre infrastructure was manufactured with just 90 tonnes of sand (silica) compared with the thousands of tonnes of copper cable it replaced! Similarly, the latest desk top computers are being designed to use materials that are over 95% recycled. In both cases the performance and capability are vastly superior, power consumption is minuscule, and the production costs are far less than previous technologies.

The Digital Revolution
The Integrated Services Digital Network (ISDN)

During the early 1970's detailed studies indicated that an all digital network would most economically service the global needs of mankind. Since that time investment in new switching and transmission technologies has seen the construction of radically new networks able to deliver capacity on demand. In the UK and much of the West this has been realised in the form of the ISDN which delivers an N x 64kbit/s channel capacity to the customer: the customer determines whether N = 2, 6 or 30 depending on needs. Extensive trials have shown such capacities to be thoroughly adequate for video conferencing (N = 6), remote endoscopy (N = 2 or 6), X-ray imaging (N = 30), ultrasonic scanning (N = 6 or 30), and so on. Such services are ubiquitously available with the same ease as the conventional telephone network (i.e., the PSTN), e.g., the bandwidth is selected upon dialling the distant end, provided both ends have the right line termination unit. Today up to 2 Mbit/s (N = 30) can be provided with ease, and within the decade this will increase to 150 Mbit/s.

Home, Office & Mobility
Modern computing and communication has, so far, mainly impacted the office and other places of work. Before the year 2000 it will have entered the home in the form of integrated entertainment and information systems - the merging of radio, TV, hi-fi, games and personal computer with telecommunications. Information will become a commodity item, accessible across the planet at insignificant cost. This will be made possible by continued advances in chip, satellite, radio and optical fibre technology that will also reach out to the home, car, and/or computer you wear. The telecommunications infrastructure to do this is already in place in terms of the fibre cable and radio infrastructure. That last mile, between the switch and the customer, can be overcome by a variety of technologies exploiting the existing copper twisted pairs, microwave radio or optical fibre. More recently developments in free space optics and Super High Frequency radio have realised further wireless options that remove the bandwidth bottleneck at the final drop to the customer, even under mobile conditions. Today, network access is readily achieved through the PSTN at rates between 14.4kbit/s to 29kbit/s, and through the ISDN at N x 64kbit/s. By the end of the millennium rates in excess of 2Mbit/s will be equally possible, and soon after we will have access beyond 155Mbit/s. Quite sufficient for instant information and experience access.

Virtual Organisations
Many organisations and companies are increasingly becoming geographicallydispersed as the need for physical co-location diminishes. Ultimately they will become virtual with people contributing and interacting in an electronic rather than physical space. People will work when and with whom they choose, having access to machine intelligence and information and their needs dictate. This will revolutionise the way businesses and economies are driven. Already we see those at the forefront establishing group environments where work packages are passed around the globe, like a baton, from one daylight zone to another. Programmes, projects, developments, creativity and collaboration can then be non-stop, non-national, but virtual, fast and far more productive and effective than today. Consultancy, design, broadcasting, newspapers, publishing, banking, insurance, telecommunications and IT are in the vanguard movement towards virtuality, with medicine and care obvious future candidates.

Anywhere - Anytime
Our ability to generate information and transport it about the planet on super highways of optical fibre is changing the way in which we communicate, work and live. The next major wave of IT development will focus on the delivery of information and experience on demand, in the right form, at the right time, at the right price to fixed or mobile terminals anywhere, over networks of optical fibre, radio, satellite, and optical wireless. Bandwidth, distance and time will no longer be significant cost elements as service and access become dominant. The cost and inconvenience of physical travel, the relative unavailability of an increasingly pressured working population, plus a general speed up of business processes make this new paradigm ever more essential.

Where Is The Money
The money devoted to the development of a future information based society can only grow at the expense of established industries and modes of operation. Looking at the distribution of available wealth in Fig 4 we see that some key areas lie outside the established IT industry. Health, education, entertainment and physical travel represent key opportunity segments, which are in turn, augmented by publishing, shopping, surface mail, and other peripheral activities.

Figure 4: Distribution of wealth

From the history of earlier industries, it is clear we can expect dramatic reductions in human involvement in manufacturing and services, with subsequent cost savings. This change will be predicated by new generations of robots, materials and manufacturing processes, releasing human and financial resources for a new society. Interestingly, the financing of the Information Wave looks to ve relatively minimal when compared to all previous change since the printing press. In the information wave everyone could have access to the technology, and should be able to participate.

When organisations and people realise that some activities are easier and cheaper with IT instead of physical travel; when it is realised that some human process is better and more efficiently completed by a machine; when cost and operational savings become evident; when competition bites, then there is no choice! Either people and organisations change or they go under!!

How will this change health care? Could the 35Bn annual budget be better spent? A major part of the spending is on community care both in the direct cost, and the massive cost of informal care. A good place to use this revolutionised communication is in the community to provide mobile health care.

You can opt out of IT, but you can't escape from it!

Physical Travel
Why do we travel vast distances just to cluster together to work in offices or meet people? The answer to this question is complex, but reasonably obvious - we come together to communicate, interact and organise ourselves and information in a rather tribal and ritualistic way. With IT this is no longer necessary or relevant in the strict sense. Many already go home to get away from distractions and do real creative work (Fig 5) The office has become an information exchange, an area of interaction, meetings and high chemistry, but in so doing is no longer conducive to pursuing one's own tasks. Solitude, isolation and concentration have to be sought in new places. In any case, the chemistry of interaction can be achieved from home using an electronic medium and we face the prospect of increasing numbers of home based or dispersed people choosing/forced to work away from any centralised office. This is not in the far future, it is happening now, as is evidenced by the number of empty office blocks and buildings throughout the West. It has been estimated that the empty office space across North America is equivalent to the geographic size of San Francisco! Companies are also migrating to "hot desking", and so are able to provide fewer desks than employees as changing habits release people from being in the office everyday. In healthcare the equivalent is the 'hot bed' - fast patient turnaround - day visits instead of confinement to a ward. This is a trend that can be expected to be accelerated by IT as well as economics.

Figure 5: Growth in the number of home workers in the USA

New Capabilities
It is now abundantly clear that developments in artificial intelligence, visualisation, virtual reality and telepresence will realise new capabilities. Human kind was not designed by mother nature to optimally cope with spread sheets, the written word, keyboards and small screens that only present a partial picture of a wider activity. Imagine a virtual reality interface with your visual cortex flooded by information from spectacles or active contact lenses, each augmented by directional audio input, tactile gloves and prosthetic arms and fingers that give you the sensation of touch, resistance and weight. Imagine also the prospect of a surrogate head that is either machine or human that can allow you to be teleported into environments anywhere on the planet with great accuracy and reality. This leads to the euphemism that is already being realised in real applications:

What you see I see, what you hear I hear, what you feel I feel!

Alternatively, contemplate the convenience of large visual displays with high definition in two or three dimensions. People could appear in full proportion with the right colour and a voice that emanates from the lips in a distortion free and convincing manner. All of this would add further to a feeling of being there!

We also need help to navigate through the growing field of information (Fig 6), find what we want, access and manipulate data so we can get down to the kernel - decision and action! The necessary technologies are all under development and use Artificial Intelligence (AI) for navigation and location, plus Hebbian decay mechanisms for filing, and automatic text summarisation. However, there are still significant problems associated with the complexity and size of systems, data bases and connectivity expected by the year 2000. These must be overcome by the equipment manufacturers, service providers and telecommunication operators working as one.

Figure 6: Growth of Information

An Ageing Population
The population of the developed world is ageing fast. There are more old people than ever before because life expectancy is now approaching 80 and the birth rate is declining. The number of peopleavailable to support this ageing population is decreasing with each new generation (Fig 7). In some parts of the world, they expect the imbalance to decline to one supporter per two adults. In Japan, this is being addressed by developing robots to undertake the caring and rehabilitation tasks, while other initiatives seek to make the human carer better trained and more effective.

Figure 7: Ratio of 15-64 year olds to over 65's

Self Help
Whilst IT can also be used to allow people to be independent for as long as possible, and informal healthcare can be transformed to self-help care, the question arises - is it possible to more effectively utilise the highly skilled and trained? For example:

• Can nursing practitioners take some of the load off GP's?
• Can GP's and nursing practitioners work together more effectively?
• Can consultants and specialists be more accessible?
• Could the social services be more effective?
• Could help be on tap when required?

Technologically this is feasible through the provision of PC's equipped with video cameras and high-resolution displays for both the consultant, GP and nursing practitioner. These can provide shared images and data, linked by mobile communications, with the GP and/or specialist/consultant assisting in the diagnosis and treatment without leaving the surgery. This might seem like a futuristic, powerful PC, but in a few years it will be available at a cost less then 500, and will form an integral part of a home entertainment and management centre!

With such technology perhaps the smart patients will be able to access medical and care help directly?

Perhaps the really smart patients will have access to the same information as the medical profession!

Real Time Monitoring
Other advances will change the balance of home care from passive to active. The same technology that allows wrist-sized computing will also provide diagnostic information and location detection. People who elect to wear such wrist devices will benefit from round-the-clock monitoring. A PC in the home is able to learn the wearer's preferences and daily routine, and thus recognise when medication has been missed or the possibility of an accident and raise the necessary alarms. Combining the two functions may allow the onset of sickness to be detected earlier and provide the means for timely treatment. Using the location detector, people who go missing can be found without the need for a police search. Alternatively, should they become ill while away from home, the device will be able to raise the alarm and inform ambulance crews where to find the person and what to be expect.

Smart Copier - Dumb Pacemaker
Many offices now employ copiers and fax machines that are smart. When the service engineer is required the machine calls for help. The same technology is finding it's way into food and drink vending machines, garage forecourts, automatic bank tellers and telephone kiosks. Soon it will enter your washing machine, tumbler drier, microwave oven, Hi-Fi, TV, and computer. None of this is life threatening - but the pacemaker is, and yet at present it is dumb! As the number of artificial body parts increases there will be a logical and necessary need to monitor both the outside and inside of humans, collect a wide variety of operational parameters, and relay them back to some 'caring computer' for analysis and action.

As a potential user I see preventative maintenance as preferable to curative medicine!

Real Time Drugs Administration
Vast amounts of time and physical space are taken up by people who currently require continual or periodic observation in hospital. Today the administration of everything from insulin to steroids requires the attention of trained medical staff. A modest amount of instrumentation would allow both monitoring and administration of the right dosage, optimised through real time bio-feedback to match an individual's body mass and metabolism. An artificial panchrias is already at a research stage, and some hospitals in the USA are experimenting with the dispensing of drugs by such mechanisms.

The next step is obvious - the patients go home and are monitored and advised from the hospital machine over the telecommunications network..

Someone To Talk To
In addition to assisting in people's physical needs, IT might be able, in some part, to satisfy and assist in their emotional needs. Networks allow virtual communities to be created anywhere on the planet without the need for introductions (Fig 8).

Figure 8: The Virtual Community

Special interest groups already abound and discuss anything of common interest and exchange experiences. People ranging from scientists to prisoners and the homeless all access and use the Internet. There are already bulletin boards for a large number of diseases and complaints including Aids, ME, MS, cancer and many more When people have access from home and are familiar with the concepts, then the use of videophones with life-sized and life-like images will create larger and better informed groups. This in turn will shrink time, distance and ignorance still further.

Perhaps there will be a new sense of belonging, new social, and patient groupings, with a means of comparing healthcare, diagnosis and treatment on a global scale!

CAMNET
The use of technology isn't confined to home visits. CamNet is a system that uses headset-mounted cameras to transmit images to a distant site. An expert viewing the images can speak to the headset wearer, and provide graphical information to a miniature screen mounted in front of one of the headset wearer's eyes. The expert and headset wearer, although perhaps many miles apart, share visual and graphical images. This system is already in use between doctors in Aberdeen and first aiders on oil rigs. By using this system on the spot first aid is improved and the hospital is better prepared if a casualty is transferred.

Telepresence - Infomatics
The population of the developed world is getting older and it is highly unlikely that there will be the resources to provide the care that is necessary. In Japan programmes are underway to manufacture robots to take on the task. Other alternatives involve the teleportation of expertise, experience and presence itself. The technologies that allow surgeons to be positioned inside the human body through an endoscope or through the use of a surrogate head peering into an incision are already with us. The prospect of remote diagnosis, inspection and surgery is real and initial experiments are underway. Before long we will see surgeons in California performing operations in London. Robots are already being used in hip replacement, brain and eye surgery. The trip to a doctors surgery or the hospital outpatient's department could soon become an automated and remote activity. Further developments include the remote monitoring of patients through electronic interfaces mounted on the body. For the diabetic and drug and medicine dependent people, it is already possible for them to be monitored at a distance by remote computers that can administer and optimise dosage. Thus far experiments have been confined to hospital wards, but there is no reason why this cannot be realised via the global telecom network.

All of these concepts can be extended to other disciplines including the repair and maintenance of oil rigs, electrnic and power installations and even activities in the home. Being able to call experts, teleport them to your location, and then have them guide you through the necessary steps to affect a solution is only a short step away - and is already being tested.

Decision Support - Artificial Intelligence (AI)
The technologies used for interacting with patients can also be used between doctors and surgeons. Currently, research is producing an exponential growth in information. New drugs that doctors need to understand are being released continuously. To benefit from this information explosion, doctors must be able to find the facts that are relevant to the task at hand. Since the early days of computing, expert systems for medical diagnosis have been a main target for Artificial Intelligence (AI) researchers. Whilst the early academic systems proved as accurate as human doctors they suffered from lack of medical confidence and accountability. However, more recently the growth in information and improvement in AI techniques, such as knowledge elicitation and representation, has seen systems surpass their human creators in accuracy. Whilst it may be a some time before automatic diagnosis is the preferred option, such systems will at least give decision support and on line reassurance in diagnosis and treatment for doctors. The artificial expertise to diagnose and treat a wider range of problems without the need to refer patients to consultants is only a short step away.

The next step of course is full or partial self diagnosis by the patient! In medical trials it has been observed that patients confide more in a machine rather than another human. The advantages and risks are obvious!

Uncertainty
Medicine as a science is characterised by the amount of analysis based on subjective data. The diagnosis process can be long and complex, relying on techniques first used by the Greeks and needing many referrals and tests which often result in uncertain conclusions by a process of elimination. In many professions it is not unusual to spend up to 85% of your time trying to find information, 10% putting it into the right format, and only 5% making the critical decision. What improvements could be made to this process?

Searching for information is a waste of human time and effort. Software "agents" are now able to roam the networks and electronic libraries across the planet, find data and retrieve it in a mater of minutes. The next step is to educate them to format the data for the individual application and human. This is only a short step away!

The single biggest impediment to realising an effective system is the huge legacy of patient data, case histories, techniques and information recorded in paper form. If all of this were available electronically, access to the global experience would be possible. Furthermore, the continual analysis and production of trend data would be feasible, also on a global scale. Hot spots, errors, corrections, new correlations and effects, new diseases, and outbreaks could be detected and be acted upon within hours rather than weeks or years. The barriers to realising such a capability are formidable, are mostly non-technical, and will probably require a further 20 years to be overcome.

Person To Machine
There is some evidence that patients often prefer an impersonal, inanimate questioner as the initial stage of the diagnostic process. Talking to a computer about personal issues may be less embarrassing and more acceptable, and allow the patient to be more candid thus improving the quality of information and subsequent diagnosis. Furthermore, it has now been demonstrated that machines can already equal the human in the preliminary diagnostic phase. It is likely that they will be able to outpace and outclass us as the amount of information increases through the use of improved biometric measurement techniques (Fig 9). In this situation AI could be a means of reducing diagnostic uncertainty as it has the potential to consider all previous case histories, diagnosis and globally!

Figure 9: Computer -v- Human evolution in abilities

Here the primary impediment to realisation is the human - machine interface. MSDOS is not something Joe Public can easily use or empathise with. Unless machine interfaces are considerably easier to use than that for a PC or similar, there is no hope for them to be generally subsumed by the populous. Indeed, this is another mechanism for the generation of an economic and health disadvantaged class. What is required is an interface that can be driven by the lowest common denominator from 5 to 90 years old. The Video on Demand (VoD) interface is the first step in this direction, and the convergence of telecommunications, computing, games, TV, radio, Hi-Fi, and entertainment might provide a more general and widely accessible entre into such an era.

Delay
What savings could be made for both the doctor and the patient if the number of tests, and delays between tests, could be reduced? How much money is tied up in paper-based systems and postal delays? How much resource is expended in merely making appointments? How many referrals result in no action required? In other industries the decision makers are having to invoke IT to become 10 to 100 times more effective. Delay is being removed by information networking, and understanding is being increased through visualisation using simulation, emulation and animation. Many high tech companies have now gone paperless throughout there management structures. If you don't have and use IT skills - and that does NOT mean a secretary doing it for you - then you don't have a job!

Patient, Doctor, It Interface
When a doctor and patient meet, in the flesh or on line, the medical records can be instantly available. For example a recent experiment in America allowed magnetic resonance images to be shared between a surgeon and the patient's own doctor many miles away. Symptoms can be recorded, and the computer can use intelligent software agents (i.e., software robots) to identify a range of causes and treatments. At the point in diagnosis when the doctor may decide to refer the patient to a specialist, the doctor can instead access the specialist's own expert system for help in further diagnosis. If the diagnosis still isn't clear the doctor can use agents to search databases world-wide for diseases etc which match the symptoms. By allowing such agents to carry diagnostic and possibly visual information, the doctor is able to get help from any medical facility connected to the network. In essence, the GP will become a cybernaut, sending agents out over the Internet to search databases world-wide to match symptoms and possible causes. When it is time to refer a patient or make a hospital appointment, an intelligent agent can check the appointment register and make a suitable appointment. If the referral is to a consultant, the patient may not need to travel. By using telepresence the GP can act as the consultant's eyes and ears and examine the patient under guidance. Specimens can be taken and sent for analysis. When the results are returned, doctor and consultant can inspect the data, images and health records without meeting and agree the most appropriate course of action.

Experiments have been held in which foetal scans have been viewed simultaneously in Queen Charlotte's Hospital in London and St Mary's Hospital in the Isle of Wight without loss of quality or definition. Similarly, endoscopic examinations on patients at Ipswich Hospital have been carried out under the guidance of a remote expert from St Mark's Hospital, London (Fig 10). In each case the links were provided by the ISDN.

Figure 10: Tele-endoscopy Link

In theory, any electronic equipment used in diagnosis can be connected over a network and the display viewed in as many places as necessary. The only limit is bandwidth, and this is rapidly being overcome by fibre optics. But what about non-electronic diagnosis? Pictures and X-rays can be transferred now without loss of quality, as is evidenced in the above two trials. In fact, the only diagnostic technique not yet available remotely is touch. By 2015 synthetic skin with all the tactile qualities of human skin will however be available. One doctor will be then able to feel what another is touching anywhere on the planet. Technology will provide telepresence and allow doctors and carers anywhere to provide the best service possible. Part of this service may be the change from a network of GP's supported by a large general hospital, to a series of 'smart' cottage hospitals supported by advanced facilities held centrally. When GP's and fund-holders are able to diagnose and treat a wider range of problems themselves, consultants and surgeons will be able to spread their expertise over wider geographic and medical areas.

Better health care in the community and improved diagnostic skills may reduce the need for general surgery and allow the surgeons to concentrate on specialist operations or supporting doctors in cottage hospitals. The same technologies that are used in diagnosis can be used in surgery. Telepresence will allow a surgeon anywhere in the world to oversee, and eventually perform, an operation somewhere else in the world. For example, researchers at the American DoD have shown that it is possible to operate remotely using crude 'remote hands' and robots. Experimental robots are currently being used in some operations in a supporting role. The AMARC programme at the University of Bristol is looking into taking robot technology into the operating theatre. Early experiments have involved robots controlled by tomographic scanners removing tumours with a precision higher than that of surgeons. One success is in Stapedotomy operations, where the surgical robot has demonstrated a performance superior to that of humans when drilling into the bone. With these successes robots are now being introduced into retinal and joint replacement surgery. However, the full benefits of this technology will not be reached until the dexterity and tactile sensations comparable with human levels has been achieved. The final piece to this will be tactile skin, which is due in 2015.

By the end of the millennia we will be able to 'place' the distant expert on the surgeons shoulder either by using a CamNet system or a surrogate head which allows the distant surgeon full control of the cameras. By linking this to a robotic arm, the remote surgeon will be able to see what is happening, inspect what he wants to see and point to features of interest to both surgeons. The remote surgeon only needs to be involved during the critical parts of the operation and can switch between patients as necessary. Their expertise can be made available anywhere as required.

VR And Visualisation
By using virtual reality constructive and plastic surgery can be practised and any difficulties overcome before performing the real thing. The operation may be practised as many times as the surgeon feels necessary before wielding a scalpel, thus enabling him to produce a 'cleaner' result with less trauma and in a much reduced theatre time. Thus both theatre resources and convalescence facilities can be better used. It is clear from trials that this technology works. As in robotic surgery, the question is not will it be available but when will it be in general use?

Virtual reality can also be merged with advanced visualisation techniques to provide a 3D landscape of data which can be flown over or walked through so that its full form and meaning can be understood. This may pay great dividends in areas such as epidemiology where the occurrence of sickness suddenly increases, reaches saturation and can quickly die away as it shifts geographic location. It then follows: could personal health monitors predict epidemics based on analysing minor changes in the physiological status of large numbers of people; and could medicine become predictive?

Remote Education & Training
We can anticipate that the very process of education will have to change in the coming years. The majority of universities are small, with even smaller departments increasingly stretched by a widening curriculum. Staff have to cope with larger numbers of students and teach a wider range of courses in a shorter time. Why then do we have say fifteen lecturers in various dispersed universities giving the same lecture on different days to different groups of students? With IT and telecommunications it is possible for all the students to attend any one of the lectures, or indeed, for the one lecture course to be prepared and broadcast by a small team at one university to all the others. This would allow specialism by department, an increased efficiency and depth of understanding, a real opportunity to conduct meaningful research, and perhaps most valuable of all an ability to allow students to mix and match modules and create their own degrees at a distance. The distributed degree among five or six key universities would then be a real possibility!

Teaching and education methodologies can also be expected to see radical change. Since the ancient Greeks we have hardly strayed from scratching in the sand. Moving to the blackboard, white board and overhead projector as most of us do today is hardly revolutionary given the technology at our disposal. Might we expect experiments on the display screen to become as respectable and valid as experiments in the laboratory? After all, they can be far more powerful and instructive! On-line tutorials, lectures and interactive teaching packages for the rapidly expanding science and technology based curriculum would seem a necessity. Indeed, packages are already being introduced in medicine and other professions. The dismantling of high tech structures, the simulation of air flow across an aircraft wing, the current flow in an electronic circuit, or the dissection of a frog or human organ are already available on trial systems. In some universities it is already impossible to get a degree qualification without your own personal computer and telecommunications link..

Perhaps in the not to distant future we will be able to cruise the world's institutions of learning, virtual or real, and drop in for a refresher course presented by an internationally recognised expert - anywhere, anytime! Perhaps project reports and theses will become interactive documents and high quality visualisation will offer immediately informative representations of physical or other situations,. Those who have tried and found the traditionally long haul of a many years education to get even a rudimentary understanding too tough, difficult, or plain indigestible, might find that visualisation and/or virtual reality puts them in the picture - at last !

Figure 11. The Knowledge Cycle

Paradoxically, IT and the future learning age is likely to see a migration away from the group of highly specialised individuals back to the "font of all knowledge" singleton that society had some two centuries ago.

In medicine this can only be to the good!

About The Author
Peter Cochrane joined the British Post Office in 1962 and is a graduate of Trent Polytechnic and Essex University. He is a fellow of the IEE, IEEE, and Royal academy of Engineering, a visiting professor to Essex, Kent and Southampton Universities. He joined BT Laboratories in 1973 and has worked on a variety of analogue and digital switching and transmission studies. He has been a consultant to numerous international companies on projects concerned with systems, networks and test equipment development. In 1978 he became manager of the Long Lines Division and directed the development of optical fibre systems, photonic amplifiers and wavelength routed networks for terrestrial and undersea applications. He received the Queen's Awarded for Technology in 1990 for the production of optical receivers for TAT­8 and the PTAT­1 undersea cable systems. In 1991 he was appointed to head the Systems Research Division at BTL which is concerned with future computing and communications developments. He was further promoted in 1993 to head the Core Technologies Research Department with 620 staff.