Setting Up a Simple Internet-Accessible Case Database for Neurosurgeons

Abstract

To the Editor: Keeping track of cases is essential for almost any neurosurgeon. Many neurosurgeons have set up databases on their personal computers to store names, medical record numbers, and images of cases that they have done. This activity is very useful because the information can be used later to verify clinical information for hospital/board certification, to write academic papers, and to judge outcomes. Because almost every neurosurgeon carries an Internet-capable mobile phone (smartphone), it should be possible that once a neurosurgeon completes a case, he or she can open the Web browser on his or her smartphone and enter the case data into a personal database on a secure remote computer. However, previously, it was frustrating to set up a fully capable, inexpensive personal or group practice database that can be accessed over the Internet (the Web). This situation, however, has changed. I want to describe for those who may not be familiar with some aspects of computer technology the ease with which this sort of database can now be constructed and set up for personal or group use. No special programming experience is required. Several different computer software packages exist for database creation. Here I illustrate the process of setting up an Internet-accessible database using Filemaker Pro 11 (Filemaker, Inc, Santa Clara, California), which is one of the most popular software packages. Setting up a database with a current database software package is relatively simple. The database creation software allows the user to set up different fields, which hold data values for each patient. These fields are then arranged in a layout, where the data will be entered and reviewed. The program saves the data for each patient as a “record.” The database for tracking operative cases would typically hold data such as “ date of surgery,” “last name,” and “procedure.” Setting up such a database can take less than 1 hour.1 The database software will allow searching, sorting, editing as well as adding and deleting records. The goal of the next step is to allow the database to be accessed from anywhere on the Internet. For this step, the computer storing the database (the database “server”) needs to have a static IP (internet protocol) address. A typical high-speed Internet connection that a consumer obtains from the local phone or cable company allows for a dynamic IP address. In other words, a new IP address is assigned periodically to the computer (often every time the computer connects to the Internet). This configuration is not adequate to communicate with the database computer routinely. Most Internet service providers (ISPs) will set up a static IP address in a home or office for a monthly subscription charge, which is slightly more than the typical home high-speed service cost. A high-speed modem connected to the cable or phone line will need to be configured by a technician from the ISP. This modem is then connected to a “router” so that the Internet connection can be shared in the home or office with several computers. The router needs to be configured so that Internet “traffic” is sent to the database server on the local (home or office) network. This assignment usually consists of setting a “port” for Internet traffic (typically port 80) to the local IP address of the server. Most consumer routers will have simple software that allows the user to do this. In addition, the server computer needs to run software that guides Internet traffic to the directory containing the database to be displayed.2 One simple computer server, which is usable almost out of the box, is the Mac Mini Server (Apple, Inc, Cupertino, California, $999 US). With a commercial database server program like Filemaker Server 11 ($999; Filemaker, Inc), the database can now be published to the Internet. First, the person who is setting up the database establishes usernames and passwords for the users. This step is important so that unauthorized access to the database is blocked. Next, with Filemaker Server 11, all the necessary files for an Internet-accessible database are created in a directory on the server. A database user then accesses the server from the Internet by using the appropriate IP address (or Web address) and directory name. The user will initially encounter a “log-in” page and enter a username and password to log in. An Internet-capable database that has been generated in this way will allow sorting, searching, adding, and deleting of records from any smartphone. I have used such an Internet-accessible database to enter more than 150 cases over the course of the past year. The system proved reliable without any problems such as loss of data or security issues. The database was useful for tracking the volume of cases performed in different categories (eg, vascular, spine, tumor), the volume at different hospitals, and the results of different procedures. To be sure, there are other database solutions available, but most are more limited than what I have described. For example, a surgeon can carry a laptop computer around and enter case data “in-the-field,” but this can be risky because the computer can be lost, damaged, or stolen, and the database may be lost or corrupted. On the other hand, office staff can be tasked with maintaining and creating a database, but this “human” solution can be unreliable and the database may be inaccessible if staff are absent or occupied. An Internet-accessible computer database like the one described here can be available at all times for data entry and query. Filemaker Inc offers a database program called Filemaker Go for Iphone or Ipad (Apple, Inc), which allows intermittent synchronization of the database on the mobile device with a database found on a home or office PC. However, this limitation adds an extra step. On the other hand, a program such as “Go to My PC” (Citrix Online, Inc, Goleta, California) can be used to access a remote computer with the database on it. This is a viable option if a high-speed Internet connection and the remote PC are always available, but it is less attractive for surgeons who may want to enter and review data primarily from a smartphone. Finally, several companies offer professional Filemaker Pro hosting services so that a consumer can upload their database to a third-party server and accomplish tasks similar to what has been described here for a monthly subscription fee. A note of caution is warranted. Once a database is filled with patient records, it becomes a precious resource. As such, users need to establish a protocol for backing up the database to guard against hardware failures or unwanted modification. Fortunately, database software can be programmed to make backups automatically. In addition, there are many options for automated backups including both software (which periodically saves a duplicate copy of the database to a new location) and hardware, such as a RAID (redundant array of inexpensive disks) drive, which provides additional security against data loss by using specialized data storage methods. Finally, the Health Insurance Portability and Accountability Act (HIPAA) regulations require that any individually identifiable health-related information be protected. Strict measures need to be taken to prevent unauthorized access to the database. Surgeons may want to anonymize their data in some way in addition to preventing unauthorized access by using password protection. In addition, the database ideally should be placed on a dedicated computer server, not a server that hosts, for example, the Web page for the neurosurgery department or the practice to further prevent any unauthorized access. Ethan A. Benardete Philadelphia, Pennsylvania