Strategies to use the Web for clinical information
Tapping into the right sites can help you cut through the clutter and find needed information—quickly
By Bryan Walpert
If you want a glimpse of the future of computers and medicine, take a look at young physicians like C. Erick Kaufman, ACP-ASIM Member.
The 35-year-old internist, who works at the Ferrell Duncan Clinic in Springfield, Mo., can tell you exactly which seven books he planned to buy when he completed residency in 1997. Perhaps more importantly, he can also tell you that he didn't buy a single copy of any of the titles.
Instead, Dr. Kaufman bought a subscription to the Web service MD Consult. For $20 a month, he can search nearly 40 texts through the site—including the titles he planned to buy--and other books from his wish list. The site is updated regularly, so he doesn't have to buy updated editions every year. And he can tap into all of those titles using his tiny PalmPilot handheld computer.
Convenience, cost and timely updates are sending a growing number of physicians like Dr. Kaufman to the Web. While the Internet can be an excellent source for specific clinical information or simply to keep abreast of the latest research, navigating the sea of online texts, journals, journal clubs and other Web sites can be frustrating.
Depending on what question you need to answer and how much time you have, some sites meet your needs better than others. Here's a primer for getting the most out of the Web.
Electronic textbooks and databases. Online texts give beginners a good way to ease into using the Web, particularly when it comes to answering exam room questions. You'll find online versions of books already on your shelf, such as "Harrison's Principles of Internal Medicine" (www.harrisonsonline.com) and "Scientific American Medicine" (www.samonline.com). Other electronic texts were developed specifically for the Web, like emedicine.com, which provides 55 texts free of charge, and UpToDate.com, which costs $495 for individual subscribers.
Proponents of electronic textbooks like to point out that you can search online editions faster and that the text is updated more frequently. But just how fast are online textbooks? Charles Safran, FACP, an internist at Beth Israel Deaconess Medical Center in Boston, recalled seeing a patient with recalcitrant psoriasis who wanted to know the most current treatments available. Dr. Safran turned to UpToDate and within a few seconds, he was able to describe the latest information on vitamin D analogues, topical steroids and other treatments.
Electronic journals. Just as traditional texts are available online, so are traditional journals such as Annals of Internal Medicine, The Journal of the American Medical Association, The New England Journal of Medicine and the British Medical Journal. If you can remember when and where you saw an article, you can usually find it online quickly.
"While most physicians like the readability of print publications, it's easier to search the Web than rummage through old magazines." said Marshall Ruffin, MD, president of the Charlottesville, Va.—based Informatics Institute, which helps physicians implement and use medical records systems and data warehouses.
The catch is that most journals don't give free access to their articles, and some even charge their print subscribers a fee to read articles online. Some journals sell subscriptions to online access separately from print subscriptions.
Specialty medical sites. Experienced Web users say that specialty sites are the most helpful when trying to answer a specific question. If you're seeking information on a drug, for example, you can go to the manufacturer's site to read the package insert. The FDA site (www.fda.gov) can also help you research drug approvals.
Keep in mind that every site has limitations. Commercial sites, for example, often include marketing information that can be biased, so read with a critical eye. Also remember that package inserts don't tell you about a drug's uses not specifically approved by the FDA.
Even the FDA site may not be your best bet if you can't remember the name of the particular drug you're looking for or when it was approved. Doctor's Guide (www.docguide.com/newdrugs/indications) provides a free list of recent drug approvals that you can scroll through quickly, explained Veronica Young, PharmD, assistant director of the drug information service at the University of Texas Health Science Center at San Antonio.
Don't trust a site unless you're familiar with it, even if it's maintained by a well-regarded university or professional association. "You can't always trust the label," said Marjorie Lazoff, MD, an emergency medicine internist in Philadelphia who edits Medicalcomputingtoday.com, a medical informatics site. "The sites might not be well-maintained because the organizations have other priorities."
Metasearch engines and aggregators. To speed the process of finding relevant sites with quality information, some sites assess content, then provide links to the best content. Examples include MedWeb (www.medweb.emory.edu/MedWeb) and Medical Matrix (www.medmatrix.org).
While these sites are popular with many physicians who use the Internet, some like Dr. Lazoff say they are not fans of sites that rate other sites. They argue that no single site can cover the ever-growing Web and that every rating system is bound to be biased. Besides, they say, these sites only provide links to other sites that you must still spend time viewing individually.
Increasingly, medical-specific search engines are filling the need for quick access to multiple sources: online journals, texts, Web sites or a combination thereof. If you're looking for one-stop shopping, a medical search engine these may be the place for you.
The best known search engine is Medline, which allows you to search more than 4,000 medical journals free of charge. (Go to the National Library of Medicine's PubMed at www.ncbi.nlm.nih.gov/PubMed).
SUMSearch, a free, nonprofit search engine, searches Medline as well as the "Merck Manual of Medical Information," the National Guideline Clearinghouse and the Database of Abstracts of Reviews of Effectiveness (DARE), which includes abstracts of reviews and protocols from the Cochrane Collaborative.
Again, the catch is that you cannot read full text of articles you find through PubMed and SUMSearch unless that journal provides its content for free—or you happen to subscribe to that journal. That's why a number of so-called aggregator sites go a step further: For one annual fee, you can retrieve textbook chapters and full-text journal articles from publications they have licensed.
MD Consult (www.mdconsult.com), for example, integrates nearly 40 reference books, practice guidelines, drug information and patient education materials. The site also allows you to search Medline and retrieve full-text articles from nearly 50 journals. Individual subscriptions cost $20 a month or a lump sum of $200 a year.
Skolar, M.D. (www.skolar.com), a commercial service developed at Stanford University, searches textbook sites, drug databases, clinical and practice guidelines, Medline, journals and evidence-based medicine reviews and abstracts from the Cochrane Collaborative. A subscription costs $240 a year.
Medscape.com, which is free after registration, offers Medline searches and a number of full-text journals and books available through its site.
Ovid Technologies (www.Ovid.com) sells its service to large group practices and institutions. The service includes Medline, as well as the full text of about 400 journals, 26 textbooks and evidence-based medicine databases. (The price begins at $2,500 for Medline, with additional fees for each full-text journal.) If your institution is connected, you can log on at gateway.ovid.com without a password.
Sometimes it's best to use more than one metasearch engine or aggregator. Dr. Kaufman, for example, suspected last year that a hospitalized patient had Addison's disease. After logging onto MD Consult at the nurse's station, he first searched a general textbook to skim symptoms and treatments to make sure he was on the right track. Then he went to an endocrinology text on the site that listed necessary tests.
The patient also had elevated eosinophil counts. To verify his suspicions, Dr. Kaufman also searched UpToDate. The site contained an article that had a table of conditions likely to cause elevated eosinophil counts—a table he did not expect to find as easily on MD Consult without wading through chapters of textbooks. The table confirmed that one cause of the symptom is Addison's.
General search engines. Experts consider general search engines like Google (www.google.com) or AltaVista (www.altavista.com) useless for general searches. Looking for information on hypertension or diabetes will produce thousands of pages of results, many irrelevant or of poor quality.
But if you're searching for information on a particularly rare condition, those search engines may do the job. A family member asked Daniel Masys, FACP, for example, a hematologist-oncologist and director of biomedical informatics at the School of Medicine at the University of California, San Diego, about spinal stenosis. A search on Google produced nearly 100 links, including some quality patient-oriented material that he printed out and sent to the family member.
"Search engines like Google are surprisingly good for researching uncommon medical topics," Dr. Masys said. "The more rare the condition, the more likely you will find something."
Keeping up. The Web is also useful for keeping up with the latest medical breakthroughs.
Dr. Lazoff recommends MDLinx (www.mdlinx.com), which allows you to read the latest clinical news by specialty, and NewsRounds (www.newsrounds.com), which personalizes a homepage based on your interests. Both are free.
Web-based journal clubs have proliferated. An example is the Web version of the College's ACP Journal Club (http://www.acpjc.org/).
A third way to keep up with the latest research is to subscribe to sites that send you e-mail about the latest breakthroughs in fields you identify. Sites like MDLinx, Amadeo (http://amedeo.com) and JADE (www.biodigital.org/jade) all send out regular e-mail updates free of charge.
Keep in mind that e-mail news services have a downside: "They can get to be too much," Dr. Masys said. "You get so much e-mail you don't have time to browse it."
Get connected. If logging on is too time-consuming or cumbersome, you're less likely to turn to the Web while a patient is waiting. Dr. Masys said that a cable or digital subscriber line (DSL)—lines always open to the Internet—can make a big difference.
"When everything is a click away, you can have an important clinical question come up and in a few seconds see the relevant information," Dr. Masys said. "That doesn't happen if you're depending on a phone line and a modem."
You might convince your health system to provide high-speed access. Dr. Kaufman's health system provides physicians access to a high-speed T1 connection. His information systems committee recently decided to buy a system-wide subscription to MD Consult, which will save him the $20 a month he pays now.
But as Dr. Kaufman is quick to point out, even that subscription fee was cheap compared to the several thousand dollars he saved by not having to buy books. Instead, he said, "My wife and I went to Mexico."
Bryan Walpert is a freelance writer in Denver.
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