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<b>ISSUE 4</b><p>
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<td ALIGN="LEFT"><font FACE="ARIAL, HELVETICA" SIZE="-1">Issue 4, March 1998</font></td>
<td ALIGN="RIGHT"><font FACE="ARIAL, HELVETICA" SIZE="-1">ISSN 1368-1591</font></td>
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<center><font FACE="ARIAL, HELVETICA" SIZE="7" COLOR="#5511CC">Personal view</font></center>
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<a NAME="Topic1"><font FACE="ARIAL, HELVETICA" SIZE="6" COLOR="#5511CC">Finding medical information on the Internet: Who should do it and what should they know</font></a>
<p>
<font FACE="ARIAL, HELVETICA" SIZE="5" COLOR="#5511CC">Introduction</font>
</p>
<p>
<font SIZE="+2">M</font>ore and more medical information is appearing on the Internet, but it is
not easy to get at the nuggets amongst all the spoil. Bruce McKenzie's
editorial in the December 1997 edition of <i>SIM Quarterly</i> <a HREF="#1">(1)</a> dealt very well with the problems
of quality, but I would suggest that the problem of accessibility is as much
of a challenge. As ever-greater quantities of high quality medical
information are published electronically, the need to be able to find it
becomes imperative. There are a number of tools to find what you want on the
Internet Ð search engines, agents, indexing and classification schemes and
hyperlinks, but their use requires care, skill and experience.
</p>
<p>
<font FACE="ARIAL, HELVETICA" SIZE="5" COLOR="#5511CC">The current scene</font>
</p>
<p>
<h3>What a library looks like</h3>
</p>
<p>
<font SIZE="+2">I</font>nformation is widely scattered around the Internet. The quality,
reliability and organisation of sites vary on a continuum from the
electronic versions of the <i>BMJ</i> and <i>Lancet</i> to the chelation and vitamin
sellers of the alternative fringe. Medical libraries are required to hold
vast numbers of journals but still have an inadequate collection for
detailed research, and smaller or poorer hospitals are inadequately served.
MEDLINE is available in most places but still has pitfalls for the unwary,
and is rarely used to its full potential. The Cochrane collaboration and the
bandwagon of meta-analysis continue to roll. Each of these information
sources is useful, but each requires different skills to use.
</p>
<p>
<h3>The Library as a clinical department</h3>
</p>
<p>
<font SIZE="+2">C</font>linical staff are expected to learn how to access information in the
library. There are never enough and never can be enough librarians to allow
all information searches to be conducted by them. When the sources of
information are standardised and validity assured by the standing of a
printed journal, then this is an almost acceptable state of affairs. The
medical and nursing students have a short course in using the library and
their superiors and mentors are usually adept at using the literature so
there is support for the junior clinician. Medical journals are a miracle of
the evolution of a standard format for delivering information, but even
then, postgraduate training is necessary to keep skills up to scratch.
</p>
<p>
<font SIZE="+2">M</font>ost libraries now offer MEDLINE courses, but the way information is
represented is multiplying too rapidly for the systems to keep up. Anyone
with over 10-15 years experience will remember the days when computerised
literature searches had to be planned with and conducted by a specialist
librarian, cost a relatively enormous amount, were slow, and produced data
in a unwieldy mass of fanfold paper. The introduction of desk top computers
and CD-ROM based MEDLINE has allowed individuals to conduct their own
searches, but there is far less support available for the intellectual task
of framing the queries, both from the librarians who have to do this in
addition to acting as technical support, and the clinical hierarchy who may
have no experience of producing such questions. The medical library has not
yet become a clinical information department.
</p>
<p>
<font FACE="ARIAL, HELVETICA" SIZE="5" COLOR="#5511CC">The next five years</font>
</p>
<p>
<h3>The emptying of the shelves</h3>
</p>
<p>
<font SIZE="+2">P</font>aper journals are migrating to the Internet at a rising rate: <i>Nature</i>, <i>BMJ</i>,
the <i>Lancet</i>, and the <i>New England Journal of Medicine</i> all have electronic versions
and are quickly moving toward full-text versions. If the popular,
general journals are accessible on the Internet, can the more specialist
ones be far behind? Subscription services have been run for a number of
years and are becoming more common in the mainstream (e.g. the <i>Economist</i>).
Here in New Zealand we are often faced with a wait of up to a week for even
air-freighted journals and up to 6 weeks for surface post. In fact many
articles are already ordered by electronic means; the reference found on
MEDLINE, the article ordered via inter-library loans, and a photocopy
delivered. How long before the final stage is just the unlocking of a
Web site?
</p>
<p>
<font SIZE="+2">L</font>ibraries are spending an ever-larger percentage of their budget on IT.
There are more journals published every year. An efficient electronic
Interloan service does away with need for subscriptions to all but the most
popular journals.
</p>
<p>
<font SIZE="+2">I</font>n five years time, I believe, many journal stacks will look like the card
index areas or the paper <i>Index Medicus</i>, deserted except for the thesis
writer and the historical researcher. The medical library of old will become
an information centre, as will every modern library. It will become the
clinical information centre; like the pathology department, it will have no
inpatients but it will be equally important to the practice of medicine. It
will also have to be available to the healthcare providers in the community,
with the decreasing cost and increasing availability of wide area networks
the information poor parts of the health system will be able to benefit from
the information rich.
</p>
<p>
<h3>The information explosion continues</h3>
</p>
<p>
<font SIZE="+2">N</font>ot all medical information on the Internet is held in duplicates of paper
journals. In fact this is a tiny subset of the information available. Much
of this non-journal material is of high quality, and as time goes by there
will be more and more internet-only publications: where the information is
too time-sensitive (e.g. epidemiological information), too voluminous (for
example the proposed data amnesty for unpublished trials), too specialised
or just of the wrong format to be reasonably available to paper libraries.
</p>
<p>
<font SIZE="+2">I</font>f we are to follow the principles of evidence-based medicine <a HREF="#2">(2)</a> then we
need to be able to access all of these sources of information. If evidence-based medicine is to be applied in a relevant and timely manner to clinical
problems then obtaining information has to be regarded as part of the
clinical process.
</p>
<p>
<font SIZE="+2">A</font>t San Francisco medical school <a HREF="#3">(3)</a> they are already providing the tools for
clinicians to access electronic medical information. More than tools are
needed; skills and support are also required if the practicing clinician is
to fulfill Archie Cochrane's dream in the 21st century.
</p>
<p>
<font FACE="ARIAL, HELVETICA" SIZE="5" COLOR="#5511CC">What skills are needed - and how can people get them</font>
</p>
<p>
<h3>Searching the Internet - a non-trivial task</h3>
</p>
<p>
<font SIZE="+2">T</font>here is a great deal more to searching for electronic information and
converting it to clinical knowledge than getting a browser a modem and a PC.
There are skills in three major areas, as well as a fourth new skill area:
</p>
<p>
<b>1. Basic computing skills</b>
</p>
<blockquote><p>
<font SIZE="+2">B</font>eing able to move around the computer in an efficient way, understanding
how to use the features of local and Internet based software and how to
learn to use new features. I regularly use at least four different
interfaces to CD-ROM based information sources (MEDLINE, INSPEC, MathSci and
Current Contents).
</p>
<p>
<font SIZE="+2">E</font>ach search engine and indexing system has its own interface, format and
editorial policy. Martin Gardner in the <i>BMJ</i> <a HREF="#4">(4)</a> has pointed out the fact
that information gatherers still need technical skills to deal with the
information sources.
</p>
<p>
<font SIZE="+2">T</font>hese skills are not trivial and there is always a danger that the user will
stick to what they know, rather than what is most appropriate because it
just takes too long to learn a new method, or they find they take too long
to carry the task out. Virtually anyone can type but only a touch typist can
take dictation.
</p>
<p>
<font SIZE="+2">T</font>he clinical information about the patient may also be located on a computer
system. Systems will continue to change and the skill to learn new systems
is an important skill.
</p>
</blockquote>
<p>
<b>2. Information management</b>
</p>
<blockquote><p>
<font SIZE="+2">T</font>hese are the traditional preserve of the librarian, but every scientific
discipline requires the ability to review and report on the current
literature. This task is made even more difficult because of the variable
quality and huge amount of material on the Internet. These skills are
important for not only locating the information but also assessing its
quality in terms of the reliability of the source (validation) and its
timeliness.
</p>
</blockquote>
<p>
<b>3. Clinical understanding</b>
</p>
<blockquote><p>
<font SIZE="+2">T</font>here are all sorts of skills here, but this is required if the information
obtained is to be transformed into knowledge that can be used to treat or
diagnose the patient (which is of course the reason why we have healthcare
anyway). Clinical understanding needs to be used to reject information that
may be inappropriate or out-of date or misleading. It is also essential to
allow the information gleaned to be presented to other clinicians in an
appropriate way.
</p>
</blockquote>
<p>
<b>4. Clinical information management</b>
</p>
<blockquote><p>
<font SIZE="+2">T</font>his brings together all the above skills as well as a leadership and
research role in the provision of clinical information. The clinical
information specialist will understand the sources of information, study
their reliability and ensure their accessibility. It is this synthesis that
creates a whole new skill.
</p>
</blockquote>
<p>
<h3>The Nuclear Medicine Model</h3>
</p>
<p>
<font SIZE="+2">I</font> will concentrate on nuclear medicine, but many of the points apply to a
number of disciplines such as pathology, public health and radiology. A
nuclear medicine department is a clinical department of a hospital,
responsible for a number of imaging procedures and sometimes administration
of some forms of radiotherapy. There are always medical staff (degree in
medicine and membership of the appropriate college) as well as radiographers
or medical physics technicians (sometimes graduates) and usually physicists
(always graduates sometimes with post-graduate qualifications). All three
groups have a large degree of patient contact, all three use sophisticated
computers and software and all three are responsible for the accuracy and
appropriateness of the tests performed which lead to changes in patient
management. All the groups can be regarded as taking part of the clinical
care of the patient.
</p>
<p>
<font SIZE="+2">O</font>n the research side all three groups may perform research Ð and present the
research at the same conferences and in the same journals although there are
more specialist journals for each group. People may often be members of
their own professional society as well as a general nuclear medicine
society.
</p>
<p>
<font SIZE="+2">T</font>raditionally, clinicians undergo a combination of examinations and
supervised experience before becoming independent practitioners. This is
generally supervised by their postgraduate college and although it may
include commercial or university run courses, it does not depend on them.
</p>
<p>
<font SIZE="+2">C</font>linical scientists, such as physicists generally undergo a period of
postgraduate university training Ðoften a MSc or PhD, and qualify for more
seniority through supervised experience only. The same sort of model applies
to engineers, where membership of the IEEE for example is based on a
combination of initial degree and experience rather than a formal
postgraduate examination Formal postgraduate qualifications are even less
important in theory for the radiographers/medical physics technicians, but
in practice the apprenticeship model is being replaced by a combination of
formal courses and post graduate
qualifications.
</p>
<p>
<font FACE="ARIAL, HELVETICA" SIZE="5" COLOR="#5511CC">So, who does the searching?</font>
</p>
<p>
<font SIZE="+2">T</font>he sort of people who will be successful in the clinical information
department will be those who have a commitment to patient care along with a
natural curiosity and a desire to manage information effectively Individual
hospitals and community groups will have different establishments, and I'm
sure that in many places the medical library will take over this role. In
terms of the source of these people the information technologists,
librarians as well as clinical staff and clerical staff will start to be
employed in this way.
</p>
<p>
<font SIZE="+2">A</font>s already happens in nuclear medicine and other departments, people will
move into this field and learn in both formal and informal ways.
</p>
<p>
<font SIZE="+2">D</font>octors will need to have some sort of College/Board certification
to progress in their career, while other workers will be more likely to gain
higher degrees and diplomas. There is starting to be a blurring of the lines
between doctors and other staff in many fields. In dentistry and public
health medicine, for example, taught masters degrees are becoming more common
and increasingly doctors are studying for the same sort of research-based
qualifications as non-clinicians. At the lower level, there are starting to
be more and more diplomas and postgraduate courses taught in this field.
Ultimately, the only difference between many clinical and non-clinical
courses is what they are called. I prefer the term medical informatics but
evidenced-based medicine covers the same field.
</p>
<p>
"<font SIZE="+2">M</font>edical Informatics is as much about computers as cardiology is about
stethoscopes" <a HREF="#5">(5)</a>
</p>
<p>
<font SIZE="+2">T</font>here are already special interest groups in the ACM, IPEM and IEEE for
computing professionals interested in medical computing, as well as medical
librarian societies (for example the Medical Librarian Association in the
US). Just as in other fields, the qualification structure will evolve, but I
think it has to be based on a combination of experience as well as learning from books. The professional societies can provide some assurance about
ethical standards, and levels of competence but this is a changing field and
any qualification will become obsolete quite quickly.
</p>
<p>
<font SIZE="+2">A</font>ll people involved in this area need a commitment to life-long learning and
those working in the education and research sector need to provide
innovative and flexible ways of keeping the professionals up with the play.
As doctors need CME points, something similar should be essential for
workers in this field. At the present time this is enforced by the
employer. I believe organisations such as SIM can fill a need if they can
facilitate education in this area.
</p>
<p>
<h3>What is to be done?</h3>
</p>
<p>
<font SIZE="+2">I</font> do not believe that SIM should attempt to become the Royal College of the
Medicinal Internet. At the same time, I see no reason why SIM (or a similar
body) should not become as well respected and important as the British
Nuclear Medicine Society. I think that SIM should stay cosmopolitan in its
membership and remain research and teaching based rather than a
professionally validating society.
</p>
<p>
<font SIZE="+2">C</font>linicians interested in the use of medical information should press their
Colleges to recognise training posts in this area, both for short
attachments for those going on to other things and as career posts (as is
the case in most specialties that have both diploma and membership schemes).
</p>
<p>
<font SIZE="+2">H</font>ospitals and other health-care providers will have to allow other staff to
become increasingly specialised in this field and work towards the
construction of the clinical information department. This will be painful as
the IT and library establishments will both see it as a loss of power but it
has to be done. The clinical information department will have to adapt
itself to the need of its users, the clinical staff, and keep sight of its
ultimate consumer; the patient.
</p>
<p>
<h3>References</h3>
</p>
<p>
<a NAME="1"> </a>
1. McKenzie, B.C. Quality Standards for health information on the
Internet. SIM Quarterly Issue 3, Dec 1997.
</p>
<p>
<a NAME="2"> </a>
2. Grimes, D.A. Introducing Evidence-Based Medicine into a Department of
Obstetrics and Gynecology. Obstet Gynecol 86(3):451-457, 1995.
</p>
<p>
<a NAME="3"> </a>
3. Rosenberg, W. and Donald, A. Evidence based medicine: an approach to
clinical problem-solving. BMJ 310:1122-1126, 1995.
</p>
<p>
<a NAME="4"> </a>
4. Gardner M. "Information retrieval for patient care" BMJ 344:950-953, 1997
</p>
<p>
<a NAME="5"> </a>
5. Coiera E. "Guide to Medical Informatics, the internet and telemedicine."
Chapman & Hall Medical 1997.
</p>
</p>
<a HREF="mailto:dparry@infoscience.otago.ac.nz">David T. Parry</a> <font SIZE="-1">MSc</font><br>
Teaching Fellow in Health Informatics<br>
Department of Information Science, University of Otago<br>
Dundedin, NZ
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Copyright © 1998 Society for the Internet in Medicine. All rights reserved.<br>
Date: March 1, 1998<br>
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