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

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From e-mail consults to textbooks on the Internet

One expert tells why internists should get involved in information technology-while they have a choice

From the January 1997 ACP Observer, copyright 1997 by the American College of Physicians.

By Edward Doyle

When Mark E. Frisse, FACP, was a chief resident at Washington University in St. Louis, Medicare introduced diagnosis-related groups (DRGs). While most of the medical world viewed DRGs as an attempt to standardize the way physicians were paid, Dr. Frisse saw it as something more.

"I saw immediately that the need for information in medical practice was going to change," he recalled. "For the first time, capitation was going to make it important for all parties to understand the actual process of medicine."

Spurred by what he saw as a need to collect and compile clinical data, Dr. Frisse went on to train in medical informatics at Stanford University, working with Silicon Valley legends such as Apple Computer and Xerox's Palo Alto Research Center (better known as PARC).

Dr. Frisse is still at Washington University, but now as director of its medical library, associate dean of the school of medicine and founder of its medical informatics division. He is active in the university's efforts to create a top-notch computer system for physicians, one that eventually will include a repository for clinical data and workstations that give physicians access to that data.

Dr. Frisse cautions that computers are simply one tool physicians can use to get clinical information and to help better care for patients. Just as importantly, he believes that physicians must get more involved in creating the technology to guarantee that their needs are met.

ACP Observer asked Dr. Frisse to discuss how physicians can expect their work to change because of information technology, and how they can benefit from these changes.

ACP Observer: How will technology change the way physicians manage clinical information in the near future?

Dr. Frisse: Because the medical libraries in most offices are very inadequate, the principle source of medical information for most practitioners is still the telephone. In the short run, information technology will foster communication between colleagues and help eliminate telephone tag. E-mail is a very valuable technology, because it allows clinicians to communicate with one another. While there are unresolved patient privacy and malpractice issues associated with e-mail, it is quite possible to buy systems that can encrypt all communications and allow secure and reliable transmission of information.

Q: But can getting a curbside consult via e-mail really help physicians?

A: It may actually preserve the way physicians get clinical information. In the 1960s and 1970s, we viewed hospitals as giant information-gathering engines. Patients were often admitted to the hospital not because they required acute intervention, but because it was the most effective way to bring together physicians and technologies to address a common patient problem. As a result, physicians were able to talk to one another in the hallway. They were able to write all their impressions in a single medical record. From a data collection standpoint, it was an extraordinarily efficient means of collaborative communication.

Now that hospital care is becoming increasingly rare, we have to reinvent the notion of the hospital, the curbside consultation and the medical record. We have to reinvent those kinds of social constructs in a digital environment so we can keep the collaborative spirit of the medical community alive.

Q: What role do you foresee for the Internet?

A: I anticipate a quantum leap forward within the next year in the delivery of clinical textbooks and journals over the Internet. Clinicians will continue to subscribe to paper-based journals for a long time to come, but the era of having to file articles so you don't lose them will disappear. The advantage of digital media is availability; there is no substitute for answering a question immediately as it arises, and that's the beauty of Internet-based systems. If you're taking care of a patient and need to retrieve an article on the prophylaxis of deep venous thrombosis that you think was in The Lancet two years ago, you can obtain that article relatively quickly, examine it and get on with patient care. I for one will be happy to pay some money to have that richness added to my professional life.

Q: Won't physicians who have a question go directly to a database like Medline rather than consult with a colleague via e-mail?

A: I prefer to communicate with a colleague over searching Medline because my colleague will have spent a lot of time discriminating between the really substantive publications and those that lack merit.

It is said that more than half of the medical literature in Medline is never cited again, not even by its own author. You can find articles in Medline demonstrating virtually any clinical point you wish to make, and that's not very valuable in the routine setting. I would much rather know what my hepatologist friend at Ochsner Clinic thinks I should do in the management of a hepatitis infection than what 10 articles from Medline say.

Q: How are providers of online clinical information addressing these kinds of quality issues to help physicians find the best information?

A: In the short term we will see what I call the "horseless carriage phenomenon" in digital publishing. When the automobile was first invented, people took a carriage, put an engine on it and called it a horseless carriage. For the most part, it did exactly what a carriage could do.

The first digital medical libraries will by and large be printed materials delivered over the Internet. Over time, a number of specialized products will emerge that will be very different from traditional archival publication. I'm not sure what these will look like, but I suspect that they address specific types of therapeutic and diagnostic information, that they will be pay-per-view and that they may never be published in the traditional medical literature at all.

Q: How will medical libraries survive this explosion of information technology?

A: I believe that the hospital library is in peril. As the price of online clinical information drops, there will be less and less of an inclination to go to the library to obtain a paper copy of something.

The dissemination of traditional materials will increasingly fall in the province of the large publishing conglomerate. No single library organization has the capital to compete with a global publishing conglomerate for information delivery.

Consequently, the widespread availability of clinical text on the Internet could very well close many hospital libraries unless hospital librarians find a way to add value to their new "middleman" role. For example, the librarian may know the most inexpensive and useful source of information for a given problem.

Q: Physicians have long been criticized for not getting involved enough in the development of information tools. Why is it so important for physicians to get more involved?

A: Although most chief information officers of health care systems have a sincere desire to deliver information services to clinicians, they are busy with more fundamental issues relating to financial issues and practice management aspects. As a result, I think that the clinical community will be left to discover the really clinically important uses of digital information. Most of the innovation in this area will come from the office of the small medical practice or the professional society, not from the top-down imperative of a health care organization.

Q: What if physicians choose not to become involved?

A: The medical record defines who we are. If information systems do not reflect the richness of our practice and the language that we use, or the value that we add to the physician-patient encounter, those details may fall out of the record and physicians will suffer greatly.

I believe our involvement with information technology is only a small part of what physicians do, and we should be judged on the totality of our professional contribution, not just on the basis of what we happen to enter in whatever computer system is available.

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