Mr. Kennedy is editor and program director of Medscape Psychiatry and associate in psychiatry in the Department of Psychiatry and Behavioral Health at Albert Einstein College of Medicine in New York City.
Acknowledgments: The author reports no financial, academic, or other support of this work.
Physicians have become more active Internet users over the past few years. Approximately 95% have online access and an estimated 62% connect to the Internet every day. Online activities that interest physicians include participation in continuing medical education, searching for drug information, E-mail communication with colleagues, and searching professional literature databases.
The Internet was devised in the late 1960s as a “network of networks” originally to be used by the United States military and government as a means of uninterrupted communication across the country. The brilliance of this network is that it established a standard way of communicating where there was no true hierarchy. Each computer on the network had the responsibility of ensuring that communication continued to the rest of the computers on the network.
The government handed the network over to academic and research institutions to use once they no longer needed it. Scientists around the world began sharing ideas, research, and clinical findings through this early network. E-mail was, and still is, the most popular use of the Internet but other forms of communication evolved including file transfer, telnet, and, eventually, the World Wide Web.
With the advent of the World Wide Web, an interactive, easy-to-use “front end” was placed on the Internet with graphics, multimedia, and the concept of “hyperlinks.” Being able to “jump” to pages on the same computer or on another computer anywhere in the world made the Internet a seemless web of connections that only required the click of a mouse.
Early and Late Adopters
Survey data initially generalized that physicians were late adopters to technology and the Internet,1 although this has changed in recent years. Some medical specialties were early adopters of computerization and use of the Internet. These were driven not only by some technically sophisticated specialists but also by those who had a vision of better medical information through the use of computers.
Computers have provided a dramatic change in medical education in the last decade, and medical schools adapted to it early on. This encouraged senior faculty, who were feeling intimidated to catch up, to become computer literate. As the “digital age” medical students graduated, the landscape of medicine transformed to incorporate our “digital senses” and the concept of extended/global communication.
How Physicians Use the Internet
According to Fulcrum Analytics survey2 of 1,200 practicing United States physicians in 2001, 95% of physicians who have online access have been on the Internet in the last 12 months (90% in 2000) and 74% have Internet access in their office. The survey divided physicians into three groups: general online users, which comprised 95% of the total of all practicing physicians; daily Internet users, which comprised 62% of practicing physicians; and professional users—those who described the Internet as essential to their practice—which comprised 21% of the physician population.
According to the researchers, these statistics represented a 5% to 9% increase since the year 2000. Other measures showed that 60% of physicians use dial-up connections, 32% use broadband, 4% have some other connection method, and 4% do not know what kind of connection they have. Of the total amount of physician Internet users, 60% access the Internet from home, 31% access it form work, 1% access it utilizing public computers, and 1% have other means.
The online activities rated as most popular include searching literature databases, access to professional society information, drug searches, E-mail communication, patient education information, continuing medical education (CME) courses, and clinical trial information (Figure).
The Internet has been described as the largest library in the world that has no card catalogue. There are literally billions of Web sites on every imaginable topic, but they serve little purpose if no one knows about them. Search engines, special Web sites that organize and keep track of other Web sites, were created to solve this problem. Some are organized into catalogues, others contain indices, and others have a combination of both. Many are categorized with human assistance while others are totally automated.
Search engines obtain information about the World Wide Web by either direct submission of a form by the Web site owner or through the accumulation of information gathered by “Web crawlers,” “spiders,” or “robots.” These “robots” are automated programs that roam the World Wide Web from one Web site to another. Some search engines take all their information from the “home page” (often merely a table of contents) while others go levels deeper into the real content of a site. New Web sites are added daily as information is culled from the World Wide Web. The more comprehensive search engines refresh their links at regular intervals to make sure that any changes or updates are included.
Since each search engine gathers different information, conducting a search with different search engines can yield inconsistent results. The analogy of a search engine being a virtual Internet card catalogue is somewhat misleading and each of several virtual card catalogues is slightly different from the other. However, all search engines use some variation of Boolean searches so that the searches can become quite specific. This is important when searching such a vast library. Combining words with “and,” “or,” “not,” or other Boolean operators allows searches to be refined. The more information you give a search, the better information you will get in return. Search results evaluate quantity, not necessarily quality. They are often based on algorithms which count the number of times a particular word is mentioned on a Web site’s home page.
It is important to remember that the Internet is a democracy (ie, anyone can post whatever material they choose). One search might turn up someone’s poetry or a scientific research paper with equal importance.
National Library of Medicine: MEDLINE
MEDLINE(www4.ncbi.nlm.nih.gov/entrez/query.fcgi), a site from the National Library of Medicine,?is probably the most widely used site by physicians and medical professionals. One of the most comprehensive collections of published material in the areas of health and medicine, MEDLINE yields specific results by allowing for Boolean operators when searching for published information or studies. The site also features special collections of information compiled by the National Institutes of Health. One of these collections is MEDLINEplus (http://medlineplus.gov), which contains information on over
500 diseases and conditions.
MEDLINE also provides lists of hospitals and physicians, a medical encyclopedia, medical dictionaries, health information in Spanish, extensive information on prescription and nonprescription drugs, health information from the media, and links to thousands of clinical trials. MEDLINEplus is updated daily and PubMed Central (www.pubmedcentral.nih.gov/), is an archive of life-science journal literature managed by the National Center for Biotechnology Information at the National Library of Medicine.
The Cochrane Collection (www.updatesoftware.com/Cochrane/default.HTM) is an online database of evidenced-based medicine. Other large databases of important medical and health-related information are Ovid (www.ovid.com/products/databases/index.cfm), which contains over 90 commercial databases and bibliographic resources in many research areas, and PsycINFO (www.apa.org/psycinfo/), which provides psychological abstracts.
Associations, Guidelines, and Publications
Sites of major associations, such as the American Psychiatric Association (APA; www.psych.org), are usually great sources of news, information, and the latest practice guidelines. Information about APA sponsored meetings, CME activities, and members is also available. Other subspecialty sites, such as the American Psychosomatic Society (www.psychosomatic.org), the Academy of Psychosomatic Medicine (www.apm.org), Geriatric Psychiatry (www.Aagpgpa.org), or Addiction (www.addictionpsych.org) offer special news, conference information, and other valuable information.
One of the best collections of practice guidelines is the National Guideline Clearing House (www.guidelines.gov). This site offers evidence-based clinical practice guidelines and is sponsored by the Agency for Healthcare Research and Quality in partnership with the American Medical Association and the American Association of Health Plans. It offers guidelines in all specialties from many sources. The site is current, searchable, and conveniently organized by topic collections.
Other important sites that are of interest are professional publisher sites. Many of these have relationships with the associations or societies that publish their journals. Some offer abstracts while others offer full-text online access to the journals. American Psychiatric Press (www.appi.org), publisher of many psychiatric journals and books, is the publishing arm of the APA. Their journals are available online in abstract format and full text for subscribers.
Medical megasites are large multispecialty sites that offer many different types of information and CME for the generalist or the specialist. Examples of these are Medscape (www.medscape.com) and Docguide (www.docguide.com). These offer news, original articles, summaries from journals, conference reports, and access to numerous journals and publications. Sites such as these are free but require registration.
The National Institute of Mental Health
Information for Patients
Patient-education information is available from a variety of sources online. The various professional organizations/associations often offer information for patients as do the medical megasites. The NIMH has a section for general information about the various mental disorders. Patient advocacy organizations, such as the National Alliance for the Mentally Ill (www.nami.org), also offer information for patients and families.
Clinical Trial Database
The Clinical Trials Database is offered under the auspices of NIH and provides access to clinical trial information (www.clinicaltrials.gov). This is a site for current information about clinical research studies, both for professionals and patients and their families.
There are a number of drug information sites on the Internet. Many are geared toward consumers and only a few are noteworthy. The National Library of Medicine has a drug reference Web site (www.nlm.nih.gov/medlineplus/druginformation.html) and the Food and Drug Administration has an online database (www.fda.gov/cder/drug/default.htm). Also on the Internet is the Physician’s Desk Reference, (www.pdr.net) a traditional source for drug references, and the Clinical Pharmacology 2000 (http://cp.gsm.com/), which is one of the better drug reference Web sites that is by subscription only.
Continuing Medical Education
Participation in CME programs on the Internet is one of the more popular online activities. A large percentage of CME credits are now being given out on the Internet each year. These programs are offered by the associations, societies, universities, and some of the larger medical Web sites. The topics are interesting and styles vary from simple slide shows to high quality clinical updates and sophisticated interactive programs.
Online CME has a distinctive advantage because it is available 24 hours a day, 7 days a week. This is a great advantage for the busy physician as the Internet traverses great distances to bring information to the desktop. Some CME sites charge per credit or per program while others are free. The most comprehensive list of online CME is organized and catalogued by Bernard Sklar, MD (www.cmelist.com/)
Taking CME to the next level with an “always on” connection (as opposed to a dial-up connection) means that credible, medical information can be available instantaneously. It is even possible to utilize the Internet for “just in time” learning at the point of care.
E-mail, the largest activity that takes place on the Internet, has evolved into an important medium of communication becoming a must in professional and personal communication. E-mail has significantly changed the speed of communication. Many physicians use E-mail to contact colleagues about referrals, report the results of a referral, obtain results of tests, or to give or receive a consultation from a specialist. According to a recent Health on the Net survey, 96% of physicians use E-mail.
A collaborative use of E-mail is called a “listserv,” a list of generally private topic-based E-mails where one needs to request permission to join in order to participate. In a listserv, all of the members receive all of the correspondence; thus, dozen of messages may appear in the mailbox if discussions are particularly active.
One of the pressing questions that physicians are currently debating is whether or not to communicate with their patients via E-mail. Before it is widely adopted, issues, such as liability and reimbursement for time, need to be addressed. In the study, 23% of all physicians reported that they interact with their patients via E-mail, up only 4% from last year, according to the Deloitte Research and Fulcrum Analytics survey.2 This is an increase from the approximate 2% who reported communicating with patients via E-mail in 1999.1 Of the doctors who do not currently E-mail their patients, 79% indicated that their preference for face-to-face contact was the primary reason for not interacting with patients online. Of those physicians, 54% say insurance reimbursement is the leading motivation for them to email their patients in the future.2
The Empowered Consumer
One consequence of the great volume of information on the Internet is that consumers now have access to a proliferation of health information. Increasingly, patients are coming to physicians offices with printouts from the health sites on the Internet. This has both positive and negative aspects to it. Patients are becoming increasingly sophisticated in their understanding of illnesses and asking more intelligent questions and feel that they can participate more in the management of their health. However, it can be problematic if the information that they obtain is not from a credible or reliable source.
Patients and families are increasingly asking their doctors for recommended Web sites to understand illnesses and obtain online support. Physicians need to be aware of some of these sites and be prepared to discuss them.
Electronic Medical Record
The electronic medical record, also known as the digital health record, will soon be available on the Internet. Because of the established standards of communication that governs the activity on the Internet, it can easily become a common link for communications between practices and hospitals with appropriate security measures. It can also empower patients/consumers to manage their portion of the digital health record in ways that previously seemed impossible. For example, patients can request appointments online, complete screening assessments before an appointment, or look up laboratory results. Physicians can monitor treatment compliance and obtain updates that may have been difficult or time consuming by telephone. Patients can actively participate in their treatment.
The future holds some interesting promises for physicians. The promise of wireless communication means access to medical records and information whenever it is needed regardless of time or location. As computers and connections become ubiquitous and virtually everyone is connected to the “network,” physicians will focus less on the machines or technology and begin to cultivate the knowledge and information that we can be accessed. Timesavers like “intelligent assistants” or “robots” are software agents that can traverse the Internet and gather information for us, make appointments, purchase things, or even order dinner.
There are vast amounts of other advantages the Internet can offer the physician as well. Hundreds of daily newspapers can be found online as are sites for sports, weather, travel, financial information, online banking, investing, and shopping. In short, the Internet is no longer a novelty, but a serious tool for communication and commerce. Just like everyone else, when asked what physicians want from the Internet, the real answer is “everything.”
The Internet has become a part our lives in many more ways than we would have imagined a decade ago. Physicians have adopted the technology of the Internet and the World Wide Web and perceive this technology as a tool to enhance productivity, knowledge, and collaboration. The Internet has facilitated communication with colleagues, institutions, and patients. It has created a global repository of high quality information that the medical profession has incorporated into its normal, daily routine. There are certainly challenges ahead in areas such as confidentiality and security but the world has gotten smaller, faster, and smarter through the opportunities that have become available through the Internet. PP
1. Health on the Net Foundation. Evolution of Internet use for health purposes – Feb/Mar 2001. Available at: www.hon.ch/Survey/FebMar2001/ survey.html. Accessed August 14, 2002.
2. Fulcrum Analytics and Deloitte Research. Taking the Pulse v 2.0: Physicians and Emerging Information Technologies. January 2002. Available at: www.cyberdialogue.com/news/ releases/2002/01-29-ful-takingthepulse.html. Accessed August 14, 2002.