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International Medical Graduates

Implications of the Internet for Medical Practice and Education

Edward H. Shortliffe, MD, PhD, MACP
College of Physicians and Surgeons
Columbia University Medical Center
New York, New York

The Internet phenomenon has had a remarkable impact on our global society in just a few short years. Health-related sites are among the most frequently accessed information resources on the Web. But despite growing enthusiasm for the Internet, any Web user can attest to its severe limitations. What will the evolving international networking infrastructure mean to the practice of medicine, to personal health practices, and to the education and involvement of patients regarding health and disease?

For practicing physicians, the Internet offers both a challenge and an opportunity. It can be difficult to gain access in some parts of the world, and in turn to learn how to take advantage of the technologies and information resources that it offers. Integrating computer use into practice workflow is particularly challenging. On the other hand, rapid access to the most current biomedical information is facilitated by the Internet in ways that were never possible in the era of print publication, when we depended on worldwide distribution via postal services. Furthermore, more of our patients are becoming facile with the Internet and use its features both to learn about health and disease and to communicate with others. Thus the Internet is resulting in a more informed public and in new opportunities for physicians to implement effective patient education and monitoring of disease outside of the traditional office or hospital settings.

On the current Internet, physicians tend to be particularly attracted to resources that provide access to the most current scientific literature (journal articles or textbooks). The Medline service of the National Library of Medicine (NLM) is now available without cost to users who can access it from anywhere in the world. With the addition of a consumer site (Medline Plus), the NLM is now a major site for high quality information that can be useful both to practitioners and their patients. Professional societies and publishers are also increasingly providing online access to current information, often without charge to the public or, at least, to their members or subscribers.

The Internet can also be used to facilitate electronic communications between patients and care providers, typically in the form of electronic mail (email). Email has been used sporadically between patients and providers, but it could prove to be an effective mechanism for improving care and lowering costs, by allowing more frequent communications that might enable better tracking of a patient's progress or eliminate the need for an office visit. The most pressing technical issue is security. Several options are available for improving the security of data exchanges between patients and providers, but the most challenging issues center around institutional policies for confidentiality and for integrating activities such as email into workflow. The Internet is also emerging as a medium for allowing consumers direct access to their personal health records, with similar security concerns.

The Internet also offers physicians the opportunity for improved monitoring of their patients and, potentially, provision of in-home care through video-based examinations or by controlling medical equipment (e.g., pacemakers, dosimeters) deployed in the home. The goals of such initiatives are to assist in early-detection of potential health problems ranging from heart attacks to congestive heart failure to diabetes and to reduce the need for clinical intervention and costly hospital stays. Continued advances in computing and communications technologies could enable more widespread deployment of affordable home-based health monitoring systems.

The Internet is becoming a significant enabler of consumer health initiatives in that it provides an increasingly accessible communications channel for reaching a growing segment of the population, and, in contrast to television, offers the possibility of greater interactivity and better tailoring of information to individual consumer needs. One recent survey in the U.S. shows that consumer sites are being used to gather information on diseases, medications, and nutrition, as well as to find care providers or participate in support groups (Table 1). The most visible aspect of this phenomenon is the explosion of sites of the World Wide Web geared toward consumer health issues, although many sites are aimed primarily at practitioners or seek to attract both kinds of users (see Table 2). These sites are dedicated to the diagnosis and management of diseases, promotion of various healthy lifestyles, and interventions to prevent the onset of disease. Due to concerns about the validity of information that is offered via such Web sites, several initiatives are under way to evaluate the quality of health information on the Internet.

TABLE 1. Health-Related Activities Conducted Online

Activity

Percent of Respondents

Research an illness or disease

62.1

Look for nutrition and fitness information

20.0

Research drugs and their interactions

11.6

Look for a doctor or hospital

3.7

Look for online medical support groups

2.3

SOURCE: USA Today, July 10, 1998

 

TABLE 2. Examples of Health-Related Web Sites. All are commercial except ACP, Cliniweb, and NLM

Site

Content

American College of Physicians (www.acponline.org)

Provides a variety of informational resources for internists, including ACP publications (Annals of Internal Medicine, ACP Journal Club, and ACP Observer).

Betterhealth.com

Covers various aspects of physical and emotional health. Includes expert advice, feature articles, and support groups.

Discoveryhealth.com

In conjunction with Intelihealth, offers disease-related information, health news, online prescription ordering, and risk-assessment services.

InteliHealth.com

A joint venture between Johns Hopkins University Hospital and Health System and Aetna U.S. Healthcare that offers health news, access to the Johns Hopkins health library, drug databases, journal abstracts, and sells catalog items.

MD Consult

Fee-based and founded by leading medical publishers that include Mosby and W.B. Saunders, MD Consult is a site for physicians that integrates peer-reviewed resources (principally journals and books) from over 50 publishers, medical societies and government agencies.

Medscape.com

Offers original, peer-reviewed reports and journal articles organized by specialty and intended for both health professionals and consumers. A dedicated consumer site is under development.

National Library of Medicine (www.nlm.nih.gov)

Offers full access to Medline through its free Pubmed and Internet Grateful Med programs, and also provides consumer health information through Medline Plus. Several other databases for practitioners are also available free of charge.

OnHealth.com

Aimed primarily at women, has an alliance with drugstore.com for pharmaceutical purchases, and offers guides that rate the health quotient of communities nationally.

WebMD.com

Started as a subscription service for doctors, but has a free consumer site that offers health news and information, a physician directory, and condition-specific support groups.

Adapted from: Ann Carns, "Today's Cybercraze is Any Web Site Devoted to Health or Maladies," Wall Street Journal, June 10, 1999, p. B1; Sharon Nash, "The Doctor is Online," PC Magazine Online, July 14, 1999.

Searching Medline

The Internet offers a wide variety of tools that can be used to find information in support of clinical practice. Examples drawn from a variety of free Web-based information resources:

  • Tools for searching bibliographic citations and their abstracts. The National Library of Medicine’s PubMed resource (http://www.ncbi.nlm.nih.gov/entrez/query) is perhaps the most commonly used literature citation search engine. The use of PubMed will be demonstrated, including some of its more advanced features such as its ability to find articles that are "similar to" another article. An alternative search engine, WebMedline (http://www.medweaver.com/cgi-bin/webmedline), will be demonstrated so show how other search engines can take advantage of the Medline database while providing search environments with varying features.

  •  
  • Tools that organize clinical information on the Internet into categories and thereby provide a "portal" for clinicians who wish to find specific information. Two excellent examples of this type of resource are MedWeb (http://www.medweb.emory.edu/MedWeb/) and Medical Matrix (http://www.medmatrix.org). The maintainers of these sites have taken on the custodial task of evaluating Web-based clinical information and organizing the sites by category after making efforts to assure their quality.

  •  
  • Tools for searching the full text of articles, providing entire journals or books online. The Web site of the American College of Physicians (http://www.acponline.org) provides full-text access to all its major publications, including the Annals of Internal Medicine (http://www.annals.org). Access to the ACP’s publications is provided without charge to members or to subscribers of the print versions.

Brief bio:

Edward H. Shortliffe is Professor and Chair of the Department of Medical Informatics at Columbia University's College of Physicians and Surgeons in New York City. During the early-1970s, he was principal developer of the medical expert system known as MYCIN. After a pause for internal medicine house-staff training at Harvard and Stanford between 1976 and 1979, he joined the Stanford internal medicine faculty where he directed an active research program in clinical information systems development. At Columbia, he continues to be closely involved with medical informatics graduate training and his research interests include the broad range of issues related to integrated decision-support systems, their effective implementation, and the role of the Internet in health care. Dr. Shortliffe is a member of the Institute of Medicine and a Master of the American College of Physicians. He is a former ACP Regent, has served on the editorial board of Annals of Internal Medicine and has served as chair of the College's Publication Committee and the Steering Committee for the Physician Information and Education Resource (PIER).

This article was prepared for the ACP IMG Web site in 2000.

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