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Time, access problems dog physicians going online

But a new NLM survey shows more health care providers trying online clinical resources like Medline

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

By Edward Doyle

While physicians are using electronic databases to get clinical information, the way they're using these tools indicates that they still aren't taking full advantage of information technology, according to new data from the National Library of Medicine (NLM).

To understand how its customers use databases like Medline, the NLM surveyed its 15,000 users, about half of whom are health care providers. The survey targeted only those customers who access NLM databases by dialing up the NLM directly or through the NLM'S Internet site, not individuals who access NLM databases through CD-ROM products or non-NLM services on the Internet. The data depict the behaviors of a relatively small group of health care providers, but they also provide a detailed look at medicine's more advanced users of computer technology.

Although health care providers represent the largest group of NLM's online users, they are not particularly frequent users. For example, nearly half of the providers surveyed search NLM databases only one to three times a month, and a quarter search less than once a month. By comparison, NLM's heaviest users, librarians, say they search NLM databases 10 or more times a month.

Details on where health care providers do most of their searching paint a less-than-ideal picture of how physicians use NLM's databases. Nearly half (49%) of the surveyed health care providers said that they primarily search from home; 40% said their primary search location is the office. Again, by comparison, power users such as librarians and scientists say they do most of their searching from the workplace.

Time and hardware

Experts in medical informatics say that the data point to a fundamental problem for physicians: Searching Medline databases requires not only specific skills, but valuable time that many practicing physicians simply cannot find in their busy day.

"Unless you're very good and have the hardware and software accessible and ready to go, it's difficult to do a Medline search in a minute or two," explained Jerome Osheroff, FACP. "You need to be willing to sit down and spend time doing some research. Even if it's only five minutes, those are five minutes that may not be readily available in an average doctor's day."

Dr. Osheroff also hypothesized that a lack of time and equipment explains why so many physicians do so much of their online searching from home. "Think about the flow of how time gets spent at the office or hospital, and it's much easier to see an NLM search fitting in at home, not work," he said. "There is also the issue of logistics. How many doctors have at their disposal a computer at a place where they can very conveniently do searches in the office?"

It is significant that more than a third of health care providers using NLM services access the Internet through a commercial online service like America Online, a sign that they probably pay for Internet access from home. By contrast, only about 20% of health care providers get to the Internet through a network, which indicates that they have access from their workplace.

Unrecognized needs

But the relatively low number of online queries by health care providers may get at an even bigger issue: many physicians may not recognize the extent to which they need information in the first place. "What doctors often say is that they see the same things over and over, and that they have very few questions," Dr. Osheroff said. "But there is good data to show that physicians have many important unrecognized information needs."

Citing data from a landmark study published in Annals of Internal Medicine in 1985, Dr. Osheroff pointed out that physicians tend to underestimate the number of questions they have while treating patients. That research, authored by David G. Covell, ACP Member, found that while physicians estimated they had about one unanswered clinical question a month, further research found they actually had many more.

In a series of similar studies, Paul N. Gorman, FACP, assistant professor of medicine and informatics at Oregon Health Sciences University, also found that physicians tend to pursue only about a third of the clinical questions that arise during practice. To find out why, he asked physicians what would cause them to try to answer a question they encountered. When physicians believed there was an answer to their question, physicians looked for an answer more than half the time; when they thought there probably was no answer, they looked for additional information only 10% of the time. In addition, physicians tended to try to answer clinical questions when the problems were urgent. "The question of what dose of a certain drug or what drug you have to prescribe is very specific," Dr. Gorman said. "You have to know the answer to do something."

This may bode well for sources of online information such as Medline. Dr. Gorman, for example, noted that when he tried to answer the questions that physicians in his research had, he found an answer about 45% of the time. The bad news, however, is that physicians

Randolph A. Miller, FACP, professor and chairman of the division of medical informatics at Vanderbilt University, also said that NLM's data offer bittersweet conclusions. "While it's a sign that things are moving in the right direction, it is also an indicator that there is still a long way to go."

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