American College of Physicians: Internal Medicine — Doctors for Adults ®

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What's on the Web for physicians-and what's coming

From the June 1996 ACP Observer, copyright 1996 by the American College of Physicians.

By Holly Epstein Ojalvo

When Michael Hogarth, MD, conducted his first Medline search in November 1994, he knew online technology was the wave of the future. He has since written "An Internet Guide for the Health Professional," now in its second edition, which also rates hundreds of World Wide Web sites. Dr. Hogarth, now a postdoctoral scholar in the division of medical informatics at the University of California, Davis Medical School, talked recently with ACP Observer about the Internet's usefulness-and limitations-for physicians.

ACP OBSERVER: How useful is the Net for practicing physicians?

DR. HOGARTH: I would use the Web, but I would not surf the Net. There are Web sites that are valuable for particular functions ... like doing Medline searching using a graphical front end. If you find a site that has particularly useful handouts, you can print them as you need them.

If you're just starting out, you can use e-mail to communicate with patients that have e-mail-you may actually improve care. Our behavior and how we use the tools have a lot of impact on their effectiveness. I would recommend at least getting an e-mail account-familiarize yourself with what's out there. The cost for a standard PC is not prohibitive. There's no need for special equipment, and Net access runs only about $20 a month.

What Web resources are particularly useful for physicians?

Patient handouts, for one. Also, the PDQ [http://oncolink.upenn.edu/pdq/] database, which has information from the National Cancer Institute. It has reference material for patients and providers on a myriad of malignancies. They have brochures that answer questions like what does it mean to have lymphoma-very patient-oriented. For physicians, it's prognosis information and references. You can also refresh your memory on what-do-I-do-next types of questions. You can print out a topic for the patient to read. NCI updates all these materials.

The key to Web info is that it needs to be continuously updated. It makes no sense to have one-and-a-half-year-old information on lymphoma. Some sites give an updated date, and some don't.

What else is the Web good for?

The Web is a nice way of sharing information, making it accessible over a wide geographic area. People are doing interesting things. ... The Mayo Clinic's graphical and hypertext linking [enables you to] navigate information-very time-efficient.

Also, there's the ability to do presentations over the Internet to a wide, geographically dispersed audience, to broadcast key presentations. This is not pie in the sky-it could be done soon, even now. We can provide CME [credit] this way.

What are some of your favorite sites?

The Virtual Hospital has multimedia textbooks that are graphically pleasing, very well-written and well-designed. There's one on travel medicine, one on pediatric airway that has X-rays and overlays of anatomy. The information is not that useful to an internist, but I find the structure of the textbooks useful and interesting.

Another good site is the interactive rounds from the University of Colorado. They present a case and the user can go through it, almost like a case presentation in a journal. You can also submit your comments. I think this idea is the key to CME in the future.

What are some downsides of the Web?

One problem, typically in the clinical set, is that physicians have particular questions that need answering-they may be patient-specific (like a lab value) or nonpatient-specific (like a drug interaction). Patient-specific information is not on the Web. Nobody in their right minds would put that kind of information there.

But the answer to nonpatient-specific information more than likely is out there. To find sites, get a book that lists them by topic. But printed lists get out of date, so I also recommend using search engines. You search by keyword on a site like AltaVista, which has catalogued every public Web page, and it will return all pages that have that keyword. After entering your query, in two seconds you get about 20 pages that match, with about 10 items on each page-that's 200 incidences in weighted order. The problem: You can't tell it you want information on coumadin in therapeutics, for example. You might get the chemical structure of coumadin, information on using coumadin in a fibrillator, something on coumadin and rat poison.

Also, physicians can't always trust information they find on the Web. I think it would help if organizations stepped in and put their seal of approval on certain sites. We need panels of experts on the topic to review sites. There should be peer review for Web sites, but if you proposed that at a board meeting, you'd probably get laughed out of the room.

Why? Are physicians afraid of technology?

No. I don't think physicians don't like technology. I think it's integrating it into their daily work-into work habits like rounds. Information services people rarely, if ever, go on rounds and see the physicians' needs. Software and front-end designers must become part of the health care team or go into a private practice for a month to look at work flow. Their view of what a doctor does is based on Marcus Welby, doctors doing physical exams. They don't know when he needs to look up information.

There have been complaints about speed-the World Wide Web is sometimes dubbed the world wide wait. Is the Net fast enough for physicians?

Absolutely. The information we want is text-based in general. Text alone is very fast, so your connection speed is almost a non-issue. You can turn images off on your browser, so you don't have to be burdened by the time it takes to see images.

And yet some physicians still don't find the Internet useful. Why?

The Web just doesn't have enough information that clinicians can use. You can get information on the fly, but it's rather general-you have to sift through to find the gold.

Two good search engines are AltaVista and Yahoo!, but they still don't catalog resources the way physicians need them to be done. If you do a search on AltaVista on foot ulcers, for example, you'll get a range of hits from a patient page to the NIH. The Web is ill-suited to do these things at present, but things are changing.

How will the Web become more useful for physicians?

Indexing. Medical Matrix is cataloguing all Internet sites that are medically related. The sites must also meet certain standards. Another good search site is CliniWeb, a catalog for health professionals. It's like using what we're already used to, but it returns Web sites instead of abstracts-you do a search and it returns pages related to your terms and describes the sites.

What's the most innovative and useful way to catalogue medical Web sites?

The best [method] would be a natural language search. It works as a decoder-it turns a question into an action. For example: What is the interaction of coumadin with erythromycin? The opposite question, What is the interaction of erythromycin with coumadin? actually looks like a different question to the computer, so it needs to learn how to parse the language to come up with the action to solve the problem. Its action may be searching Medline or CliniWeb and then reporting back.

The hottest topic on the Internet now is agents. You register [at a site with agents] and ask questions, and the agent performs an action. An example: Tell the agent to inform you when a Web site like Virtual Hospital has changed or added information. The agent's action is to check the site and to report back when it has changed. It's free now, but there will be a nominal fee for subscriptions in the future.

What do you see in the future of Web technology?

People are going to have applications, such as video conferencing, running on computers using the Internet. Telemedicine will be implementable on a wide scale.

The Internet will continue to be a communication medium. We might use something like a Web browser, but the front end might be different. We'll have a customizable Web browser to meet your needs.

Will there be Web access at the bedside?

No question-it's coming. You either become more efficient or cut back quality of care-so, you become more efficient. There are definite advantages to using this kind of technology in an academic center, in a hospital setting or in private practice. Imagine a solo practitioner who can get on video conferencing and present a case-do curbsiding-when necessary.

The information age is here. Health care can benefit enormously from us having quality information resources available to us at the point of care in a timely fashion. The Net can do that-the information is there. The means are there. We just have to mold it to our needs.

The second edition is available in print for $29.95 plus shipping and handling. Dr. Hogarth will shortly publish his second book, "Pocket Guide to the Medical Internet." Cost: $7.95. Information on both books: 800-633-1851 from the western United States and 800-241-6551 from the eastern United States.

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