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  3. <title>SIM Quarterly [Personal view, ISSUE 4]</title>
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  19. <b>ISSUE 4</b><p>
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  51. &nbsp;&nbsp;&nbsp;
  52. <img ALIGN="MIDDLE" SRC="../images/sim_quarterly.gif" ALT="[ SIM Quarterly ]" WIDTH="244" HEIGHT="83"></font>
  53. <p>
  54. <table BORDER="0" WIDTH="465">
  55. <tr>
  56. <td ALIGN="LEFT"><font FACE="ARIAL, HELVETICA" SIZE="-1">Issue 4, March 1998</font></td>
  57. <td ALIGN="RIGHT"><font FACE="ARIAL, HELVETICA" SIZE="-1">ISSN 1368-1591</font></td>
  58. </tr>
  59. </table>
  60. <hr WIDTH="465" SIZE="4" NOSHADE ALIGN="LEFT">
  61. <p>
  62. <!-- End header -->
  63.  
  64.  
  65. <p>
  66. <center><font FACE="ARIAL, HELVETICA" SIZE="7" COLOR="#5511CC">Personal view</font></center>
  67. <p>
  68. <hr SIZE="4">
  69. <p>
  70.  
  71. <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>
  72.  
  73. <p>
  74. <font FACE="ARIAL, HELVETICA" SIZE="5" COLOR="#5511CC">Introduction</font>
  75. </p>
  76.  
  77.  
  78. <p>
  79. <font SIZE="+2">M</font>ore and more medical information is appearing on the Internet, but it is
  80. not easy to get at the nuggets amongst all the spoil.  Bruce McKenzie's
  81. editorial in the December 1997 edition of <i>SIM Quarterly</i> <a HREF="#1">(1)</a> dealt very well with the problems
  82. of quality, but I would suggest that the problem of accessibility is as much
  83. of a challenge. As ever-greater quantities of high quality medical
  84. information are published electronically, the need to be able to find it
  85. becomes imperative. There are a number of tools to find what you want on the
  86. Internet&nbsp;Ð&nbsp;search engines, agents, indexing and classification schemes and
  87. hyperlinks, but their use requires care, skill and experience.
  88. </p>
  89.  
  90. <p>
  91. <font FACE="ARIAL, HELVETICA" SIZE="5" COLOR="#5511CC">The current scene</font>
  92. </p>
  93.  
  94. <p>
  95. <h3>What a library looks like</h3>
  96. </p>
  97.  
  98. <p>
  99. <font SIZE="+2">I</font>nformation is widely scattered around the Internet. The quality,
  100. reliability and organisation of sites vary on a continuum from the
  101. electronic versions of the <i>BMJ</i> and <i>Lancet</i> to the chelation and vitamin
  102. sellers of the alternative fringe. Medical libraries are required to hold
  103. vast numbers of journals but still have an inadequate collection for
  104. detailed research, and smaller or poorer hospitals are inadequately served.
  105. MEDLINE is available in most places but still has pitfalls for the unwary,
  106. and is rarely used to its full potential. The Cochrane collaboration and the
  107. bandwagon of meta-analysis continue to roll. Each of these information
  108. sources is useful, but each requires different skills to use.
  109. </p>
  110.  
  111.  
  112. <p>
  113. <h3>The Library as a clinical department</h3>
  114. </p>
  115.  
  116. <p>
  117. <font SIZE="+2">C</font>linical staff are expected to learn how to access information in the
  118. library. There are never enough and never can be enough librarians to allow
  119. all information searches to be conducted by them.  When the sources of
  120. information are standardised and validity assured by the standing of a
  121. printed journal, then this is an almost acceptable state of affairs. The
  122. medical and nursing students have a short course in using the library and
  123. their superiors and mentors are usually adept at using the literature so
  124. there is support for the junior clinician. Medical journals are a miracle of
  125. the evolution of a standard format for delivering information, but even
  126. then, postgraduate training is necessary to keep skills up to scratch.
  127. </p>
  128.  
  129. <p>
  130. <font SIZE="+2">M</font>ost libraries now offer MEDLINE courses, but the way information is
  131. represented is multiplying too rapidly for the systems to keep up. Anyone
  132. with over 10-15 years experience will remember the days when computerised
  133. literature searches had to be planned with and conducted by a specialist
  134. librarian, cost a relatively enormous amount, were slow, and produced data
  135. in a unwieldy mass of fanfold paper. The introduction of desk top computers
  136. and CD-ROM based MEDLINE has allowed individuals to conduct their own
  137. searches, but there is far less support available for the intellectual task
  138. of framing the queries, both from the librarians who have to do this in
  139. addition to acting as technical support, and the clinical hierarchy who may
  140. have no experience of producing such questions. The medical library has not
  141. yet become a clinical information department.
  142. </p>
  143.  
  144.  
  145. <p>
  146. <font FACE="ARIAL, HELVETICA" SIZE="5" COLOR="#5511CC">The next five years</font>
  147. </p>
  148.  
  149.  
  150. <p>
  151. <h3>The emptying of the shelves</h3>
  152. </p>
  153.  
  154. <p>
  155. <font SIZE="+2">P</font>aper journals are migrating to the Internet at a rising rate: <i>Nature</i>, <i>BMJ</i>,
  156. the <i>Lancet</i>, and the <i>New England Journal of Medicine</i> all have electronic versions
  157. and are quickly moving toward full-text versions. If the popular,
  158. general journals are accessible on the Internet, can the more specialist
  159. ones be far behind? Subscription services have been run for a number of
  160. years and are becoming more common in the mainstream (e.g. the <i>Economist</i>).
  161. Here in New Zealand we are often faced with a wait of up to a week for even
  162. air-freighted journals and up to 6 weeks for surface post. In fact many
  163. articles are already ordered by electronic means; the reference found on
  164. MEDLINE, the article ordered via inter-library loans, and a photocopy
  165. delivered. How long before the final stage is just the unlocking of a
  166. Web site?
  167. </p>
  168.  
  169. <p>
  170. <font SIZE="+2">L</font>ibraries are spending an ever-larger percentage of their budget on IT.
  171. There are more journals published every year. An efficient electronic
  172. Interloan service does away with need for subscriptions to all but the most
  173. popular journals.
  174. </p>
  175.  
  176. <p>
  177. <font SIZE="+2">I</font>n five years time, I believe, many journal stacks will look like the card
  178. index areas or the paper <i>Index Medicus</i>, deserted except for the thesis
  179. writer and the historical researcher. The medical library of old will become
  180. an information centre, as will every modern library. It will become the
  181. clinical information centre; like the pathology department, it will have no
  182. inpatients but it will be equally important to the practice of medicine. It
  183. will also have to be available to the healthcare providers in the community,
  184. with the decreasing cost and increasing availability of wide area networks
  185. the information poor parts of the health system will be able to benefit from
  186. the information rich.
  187. </p>
  188.  
  189. <p>
  190. <h3>The information explosion continues</h3>
  191. </p>
  192.  
  193. <p>
  194. <font SIZE="+2">N</font>ot all medical information on the Internet is held in duplicates of paper
  195. journals. In fact this is a tiny subset of the information available. Much
  196. of this non-journal material is of high quality, and as time goes by there
  197. will be more and more internet-only publications: where the information is
  198. too time-sensitive (e.g. epidemiological information), too voluminous (for
  199. example the proposed data amnesty for unpublished trials), too specialised
  200. or just of the wrong format to be reasonably available to paper libraries.
  201. </p>
  202.  
  203. <p>
  204. <font SIZE="+2">I</font>f we are to follow the principles of evidence-based medicine <a HREF="#2">(2)</a> then we
  205. 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
  206. problems then obtaining information has to be regarded as part of the
  207. clinical process.
  208. </p>
  209.  
  210. <p>
  211. <font SIZE="+2">A</font>t San Francisco medical school <a HREF="#3">(3)</a> they are already providing the tools for
  212. clinicians to access electronic medical information. More than tools are
  213. needed; skills and support are also required if the practicing clinician is
  214. to fulfill Archie Cochrane's dream in the 21st century.
  215. </p>
  216.  
  217. <p>
  218. <font FACE="ARIAL, HELVETICA" SIZE="5" COLOR="#5511CC">What skills are needed&nbsp;-&nbsp;and how can people get them</font>
  219. </p>
  220.  
  221.  
  222.  
  223. <p>
  224. <h3>Searching the Internet - a non-trivial task</h3>
  225. </p>
  226.  
  227. <p>
  228. <font SIZE="+2">T</font>here is a great deal more to searching for electronic information and
  229. converting it to clinical knowledge than getting a browser a modem and a PC.
  230. There are skills in three major areas, as well as a fourth new skill area:
  231. </p>
  232.  
  233. <p>
  234. <b>1. Basic computing skills</b>
  235. </p>
  236.  
  237. <blockquote><p>
  238. <font SIZE="+2">B</font>eing able to move around the computer in an efficient way, understanding
  239. how to use the features of local and Internet based software and how to
  240. learn to use new features. I regularly use at least four different
  241. interfaces to CD-ROM based information sources (MEDLINE, INSPEC, MathSci and
  242. Current Contents).
  243. </p>
  244.  
  245. <p>
  246. <font SIZE="+2">E</font>ach search engine and indexing system has its own interface, format and
  247. editorial policy. Martin Gardner in the <i>BMJ</i> <a HREF="#4">(4)</a> has pointed out the fact
  248. that information gatherers still need technical skills to deal with the
  249. information sources.
  250. </p>
  251.  
  252. <p>
  253. <font SIZE="+2">T</font>hese skills are not trivial and there is always a danger that the user will
  254. stick to what they know, rather than what is most appropriate because it
  255. just takes too long to learn a new method, or they find they take too long
  256. to carry the task out. Virtually anyone can type but only a touch typist can
  257. take dictation.
  258. </p>
  259.  
  260. <p>
  261. <font SIZE="+2">T</font>he clinical information about the patient may also be located on a computer
  262. system. Systems will continue to change and the skill to learn new systems
  263. is an important skill.
  264. </p>
  265. </blockquote>
  266. <p>
  267. <b>2. Information management</b>
  268. </p>
  269.  
  270. <blockquote><p>
  271. <font SIZE="+2">T</font>hese are the traditional preserve of the librarian, but every scientific
  272. discipline requires the ability to review and report on the current
  273. literature. This task is made even more difficult because of the variable
  274. quality and huge amount of material on the Internet. These skills are
  275. important for not only locating the information but also assessing its
  276. quality in terms of the reliability of the source (validation) and its
  277. timeliness.
  278. </p>
  279. </blockquote>
  280. <p>
  281. <b>3. Clinical understanding</b>
  282. </p>
  283.  
  284. <blockquote><p>
  285. <font SIZE="+2">T</font>here are all sorts of skills here, but this is required if the information
  286. obtained is to be transformed into knowledge that can be used to treat or
  287. diagnose the patient (which is of course the reason why we have healthcare
  288. anyway). Clinical understanding needs to be used to reject information that
  289. may be inappropriate or out-of date or misleading. It is also essential to
  290. allow the information gleaned to be presented to other clinicians in an
  291. appropriate way.
  292. </p>
  293. </blockquote>
  294. <p>
  295. <b>4. Clinical information management</b>
  296. </p>
  297.  
  298. <blockquote><p>
  299. <font SIZE="+2">T</font>his brings together all the above skills as well as a leadership and
  300. research role in the provision of clinical information. The clinical
  301. information specialist will understand the sources of information, study
  302. their reliability and ensure their accessibility. It is this synthesis that
  303. creates a whole new skill.
  304. </p>
  305. </blockquote>
  306. <p>
  307. <h3>The Nuclear Medicine Model</h3>
  308. </p>
  309.  
  310. <p>
  311. <font SIZE="+2">I</font> will concentrate on nuclear medicine, but many of the points apply to a
  312. number of disciplines such as pathology, public health and radiology. A
  313. nuclear medicine department is a clinical department of a hospital,
  314. responsible for a number of imaging procedures and sometimes administration
  315. of some forms of radiotherapy. There are always medical staff  (degree in
  316. medicine and membership of the appropriate college) as well as radiographers
  317. or medical physics technicians (sometimes graduates) and usually physicists
  318. (always graduates sometimes with post-graduate qualifications). All three
  319. groups have a large degree of patient contact, all three use sophisticated
  320. computers and software and all three are responsible for the accuracy and
  321. appropriateness of the tests performed which lead to changes in patient
  322. management. All the groups can be regarded as taking part of the clinical
  323. care of the patient.
  324. </p>
  325.  
  326. <p>
  327. <font SIZE="+2">O</font>n the research side all three groups may perform research Ð and present the
  328. research at the same conferences and in the same journals although there are
  329. more specialist journals for each group. People may often be members of
  330. their own professional society as well as a general nuclear medicine
  331. society.
  332. </p>
  333.  
  334. <p>
  335. <font SIZE="+2">T</font>raditionally, clinicians undergo a combination of examinations and
  336. supervised experience before becoming independent practitioners. This is
  337. generally supervised by their postgraduate college and although it may
  338. include commercial or university run courses, it does not depend on them.
  339. </p>
  340.  
  341. <p>
  342. <font SIZE="+2">C</font>linical scientists, such as physicists generally undergo a period of
  343. postgraduate university training Ðoften a MSc or PhD, and qualify for more
  344. seniority through supervised experience only. The same sort of model applies
  345. to engineers, where membership of the IEEE for example is based on a
  346. combination of initial degree and experience rather than a formal
  347. postgraduate examination Formal postgraduate qualifications are even less
  348. important in theory for the radiographers/medical physics technicians, but
  349. in practice the apprenticeship model is being replaced by a combination of
  350. formal courses and post graduate
  351. qualifications.
  352. </p>
  353.  
  354. <p>
  355. <font FACE="ARIAL, HELVETICA" SIZE="5" COLOR="#5511CC">So, who does the searching?</font>
  356. </p>
  357.  
  358.  
  359.  
  360. <p>
  361. <font SIZE="+2">T</font>he sort of people who will be successful in the clinical information
  362. department will be those who have a commitment to patient care along with a
  363. natural curiosity and a desire to manage information effectively Individual
  364. hospitals and community groups will have different establishments, and I'm
  365. sure that in many places the medical library will take over this role. In
  366. terms of the source of these people the information technologists,
  367. librarians as well as clinical staff and clerical staff will start to be
  368. employed in this way.
  369. </p>
  370.  
  371. <p>
  372. <font SIZE="+2">A</font>s already happens in nuclear medicine and other departments, people will
  373. move into this field and learn in both formal and informal ways.
  374. </p>
  375.  
  376. <p>
  377. <font SIZE="+2">D</font>octors will need to have some sort of College/Board certification
  378. to progress in their career, while other workers will be more likely to gain
  379. higher degrees and diplomas. There is starting to be a blurring of the lines
  380. between doctors and other staff in many fields. In dentistry and public
  381. health medicine, for example, taught masters degrees are becoming more common
  382. and increasingly doctors are studying for the same sort of research-based
  383. qualifications as non-clinicians. At the lower level, there are starting to
  384. be more and more diplomas and postgraduate courses taught in this field.
  385. Ultimately, the only difference between many clinical and non-clinical
  386. courses is what they are called. I prefer the term medical informatics but
  387. evidenced-based medicine covers the same field.
  388. </p>
  389.  
  390. <p>
  391. &quot;<font SIZE="+2">M</font>edical Informatics is as much about computers as cardiology is about
  392. stethoscopes&quot; <a HREF="#5">(5)</a>
  393. </p>
  394.  
  395. <p>
  396. <font SIZE="+2">T</font>here are already special interest groups in the ACM, IPEM and IEEE for
  397. computing professionals interested in medical computing, as well as medical
  398. librarian societies (for example the Medical Librarian Association in the
  399. US). Just as in other fields, the qualification structure will evolve, but I
  400. 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
  401. ethical standards, and levels of competence but this is a changing field and
  402. any qualification will become obsolete quite quickly.
  403. </p>
  404.  
  405. <p>
  406. <font SIZE="+2">A</font>ll people involved in this area need a commitment to life-long learning and
  407. those working in the education and research sector need to provide
  408. innovative and flexible ways of keeping the professionals up with the play.
  409. As doctors need CME points, something similar should be essential for
  410. workers in this field. At the present time this is enforced by the
  411. employer. I believe organisations such as SIM can fill a need if they can
  412. facilitate education in this area.
  413. </p>
  414.  
  415.  
  416. <p>
  417. <h3>What is to be done?</h3>
  418. </p>
  419.  
  420. <p>
  421. <font SIZE="+2">I</font> do not believe that SIM should attempt to become the Royal College of the
  422. Medicinal Internet. At the same time, I see no reason why SIM (or a similar
  423. body) should not become as well respected and important as the British
  424. Nuclear Medicine Society. I think that SIM should stay cosmopolitan in its
  425. membership and remain research and teaching based rather than a
  426. professionally validating society.
  427. </p>
  428.  
  429. <p>
  430. <font SIZE="+2">C</font>linicians interested in the use of medical information should press their
  431. Colleges to recognise training posts in this area, both for short
  432. attachments for those going on to other things and as career posts (as is
  433. the case in most specialties that have both diploma and membership schemes).
  434. </p>
  435.  
  436. <p>
  437. <font SIZE="+2">H</font>ospitals and other health-care providers will have to allow other staff to
  438. become increasingly specialised in this field and work towards the
  439. construction of the clinical information department. This will be painful as
  440. the IT and library establishments will both see it as a loss of power but it
  441. has to be done. The clinical information department will have to adapt
  442. itself to the need of its users, the clinical staff, and keep sight of its
  443. ultimate consumer; the patient.
  444. </p>
  445.  
  446.  
  447. <p>
  448. <h3>References</h3>
  449. </p>
  450.  
  451. <p>
  452. <a NAME="1"> </a>
  453. 1. McKenzie, B.C. Quality Standards for health information on the
  454. Internet. SIM Quarterly Issue 3, Dec 1997.
  455. </p>
  456.  
  457. <p>
  458. <a NAME="2"> </a>
  459. 2. Grimes, D.A. Introducing Evidence-Based Medicine into a Department of
  460. Obstetrics and Gynecology. Obstet Gynecol 86(3):451-457, 1995.
  461. </p>
  462.  
  463. <p>
  464. <a NAME="3"> </a>
  465. 3. Rosenberg, W. and Donald, A. Evidence based medicine: an approach to
  466. clinical problem-solving. BMJ 310:1122-1126, 1995.
  467. </p>
  468.  
  469. <p>
  470. <a NAME="4"> </a>
  471. 4. Gardner M. &quot;Information retrieval for patient care&quot; BMJ 344:950-953, 1997
  472. </p>
  473.  
  474. <p>
  475. <a NAME="5"> </a>
  476. 5. Coiera E. &quot;Guide to Medical Informatics, the internet and telemedicine.&quot;
  477. Chapman &amp; Hall Medical 1997.
  478. </p>
  479.  
  480.  
  481.  
  482.  
  483. </p>
  484.  
  485. <a HREF="mailto:dparry@infoscience.otago.ac.nz">David T. Parry</a> <font SIZE="-1">MSc</font><br>
  486. Teaching Fellow in Health Informatics<br>
  487. Department of Information Science, University of Otago<br>
  488. Dundedin, NZ 
  489. <p>
  490.  
  491.  
  492. <!-- BEGIN NAVIGATION CELL -->
  493. <hr SIZE="3">
  494. <font FACE="ARIAL, HELVETICA" SIZE="-1">
  495. <a HREF="contents.html">CONTENTS</a> |
  496. <a HREF="editorial.html">EDITORIAL</a> |
  497. <a HREF="news.html">NEWS</a> |
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  499. <b>VIEWS &amp; POSITIONS</b> | 
  500. <a HREF="events.html">EVENTS DIARY</a> |
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  502. <a HREF="MAILTO:simq@cybertas.demon.co.uk">SEND COMMENT</a> |
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  511. <p>
  512. <img SRC="../images/logo.gif" WIDTH="32" HEIGHT="21" ALT="[ Logo ]" BORDER="0">
  513. <a HREF="http://www.mednet.org.uk/mednet/">Society for the Internet in Medicine</a>
  514. <p>
  515. <font SIZE="-1">
  516. Comments to: <a HREF="mailto:simq@cybertas.demon.co.uk">simq@cybertas.demon.co.uk</a><br>
  517. <br>
  518. Copyright © 1998 Society for the Internet in Medicine. All rights reserved.<br>
  519. Date: March 1, 1998<br>
  520. Document URL: http://www.cybertas.demon.co.uk/simq/issue4/views.html<br>
  521. </font>  
  522. <p>
  523. <!-- END FOOTER CELL -->
  524.  
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  529.  
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