An Introduction to Cyberspace for Medical Professionals BY Sheldon Chang, MSPT Physical Therapist

Digital literature is more than just a new spin on an old medium. In the past, when high tech versions of previously available information becomes available, the tendency has been to scoff at them as nothing more than wasteful novelties. Indeed, if we were trying to replace all printed resources with electronic ones, we would be using the electronic medium for the sake of its novelty. In the current reality, the intent of on-line information providers is to supplement printed material rather than replace them outright.

Print and digital mediums each have its strengths and weaknesses. Like supermarkets and convenience stores, people use each for different reasons. When it comes to user friendliness, what computer program can beat the accessibility and familiarity of a favorite reference book, dog eared and worn from frequent consultations? When it comes to malleability of information, what textbook can beat a web site's ability to update and reshape information on a whim? What is more cost and time efficient if one has a simple inquiry, to sit down and punch out a detailed e-mail to a mailing list or pick up the phone and get in touch with a local colleague? The key to benefiting from the on-line medium is learning to integrate rather than replace--a simple, but overlooked point.

Aesthetics, portability, and other given weaknesses aside, electronic literature has many qualities that makes it useful especially to research oriented populations. [9, 33] One very useful feature of electronic text is that it is keyword searchable, meaning that the reader can automatically jump to every place in a document where a key word or phrase appears. Keyword searching affords the user the ultimate subject index. Another useful quality is the ease of replicating electronic information which can be cut and pasted or cheaply duplicated from source without loss of quality. Also because digital information can be directly transmitted over a network, patient data, research findings, radiographs, data analysis, insurance reports, etc. are much more easily and efficiently exchanged between parties than through faxes or having documents brutalized by mail delivery services.

Through a trickle down type of effect, electronic forums (especially in long discussions) often have an ability to enrich total input by drawing in the commentary of otherwise silent listeners.

Only a year ago, quality medical information available on-line were slim pickings. Good information still isn't quite abundant (yet), but it no longer takes computer scientist to unearth the gems hidden in a sea of pseudo-information. Whereas once there were only a handful of professional homepages that gave the user information on how to contact the organization via the telephone or regular mail to receive information, today there is a growing database of usable medical literature on the WWW. The medical Internet now features on-line journals (both exclusive and electronic versions of print editions), electronic textbooks, news services, continuing education classes, clinical practice guidelines, patient education handouts, drug databases, discussion forums, image and video clip libraries, and interactive programs among other things.

It seems that the health professions, once hesitant to embrace the changes of emerging information technology, have woken up and are beginning to take advantage of on-line resources. The surging interest (and concern) over the utility of the WWW and Internet is reflected in the increasing quantity of scientific literature from many backgrounds that are beginning to address professional issues of the Internet.

The developing information technologies of the Internet promise to create a drastic shift in the way that the medical community exchanges information and communicates. A look at the great debate over the usefulness of paper-based journals vs. the growing number of digitized journals is a good indication of the great and sudden impact that the Internet has had on the way the healthcare industry views electronic communication.

The status quo of journal publications is still a reality dominated by the printed and bound variety, but electronic based scientific publishing has gained ground on the conventional print journal. The electronic journal has emerged and continues to grow despite coming upon a hesitant and even resistant audience threatened by a change in the way that new scientific information is brought into the world of medical research. Converts of the electronic medium point out that electronic publishing is a way of decentralizing control of intellectual property and putting the author back in charge his own work while improving the exposure of information [16, 25]. Critics will be quick to bring up concerns about self-publishing posing a threat to the livelihood of scientific journals and issues surrounding quality of information [9, 32].

A 1996 study by the Library Information Technology Center (LITC) of the UK on electronic copyright management systems (ECMS) suggested for alternative copyright controls on scientific information based on its unique qualities in comparison to "commercial" publications. In commercial publications, the author and the publisher have an interest in restricting readership to paying customers only because they make money from the sale of their product. [9, 32] In contrast, academic writing has virtually no market and costs of production are reclaimed through subscription fees. In the academic scenario, the publisher has an interest in restricting readership to hopefully garner a larger subscriber base, but the author, who receives no monetary compensation, is interested in maximum exposure of his or her research [9, 16, 25].

For the reason that academic writing has very little demand, [9, 16] the LITC report determined that a pay-per-article basis of document delivery to be fiscally impractical due to the high charges that would need to be levied per document. Their suggestion is to implement a subscription-based site licensing model that would allow publishers to fund themselves while giving readers the liberty of what is done with the literature so long as a level of subscription is maintained [9].On a more radical page, author subsidized production costs have also been suggested in return for free and open access to the academic and scientific community. [9, 16]

Not everyone has to be a pioneer. Medicine and society will always need the consistent steadfast traditionals who remain guardians, developers, and promoters of the classic values and skills of a profession.

Ovid Technologies, a leading company in the growing industry of electronic literature, is one example of an electronic document delivery service. Ovid, in addition to providing an interface and access to over 90 biomedical and scientific databases such as MEDLINE, ERIC, CancerLit, and PsycINFO, also boasts over 350 journal titles in its full text collection. [35] Titles include the Journal of the American Medical Association, The Lancet, New England Journal of Medicine, and Science. Access can be obtained either through a subscription service or on a pay-per-article basis.

A unique and important advantage of electronic publishing is the enhanced ability to entertain discussions and invite commentary. One author on a cyber-psychology mailing list commented that his on-line publications have resulted in far more professional contacts than all of his printed works put together." Furthermore, he adds that his pre-Internet publications, once put on-line generated additional commentary from his professional community. Authors of pre-prints could especially benefit from the ability to present drafts to a scientific community for commentary [6]. Some researchers even put up their works in progress and invite discussion from their colleagues around the world. With the multimedia nature of the WWW, presentations of studies are free to contain sound and video--something that print media will never accomplish.

Print media, however, has its place and will always enjoy certain advantages over electronic media. One advantage it enjoys as of is that it is tested and proven unlike its electronic sister, full of potential, but having only speculation to back her up. The balance of power will change, but the emergence of the on-line medium will no more spell doom for the printed medium any more than supermarkets have pushed convenience stores to extinction.

Another advantage that print journals enjoy is owed to the conservative nature of the scientific community (not to mention its computer illiteracy) hesitant to embrace change to a new model of publishing as well as the interest of high powered journals in resisting a change that may dilute its prestige and power. Though electronic scientific publishing has made surprising gains in only a year, the politics of modern science may work against their continued growth. [9, 16, 32] In the past, the difficulty and expense of publishing scientific information has encouraged a research environment dominated by a relatively small group of elite who publish in a relatively small number of journals with prestigious reputations. Since the power of distribution is not as advantageous in the electronic medium, the upper echelon of scientific publications may choose to resist the digitization of academia and create a divide in scientific journals in which the electronic versions become synonymous with mediocre science [9, 32].

Regardless of how the controlling institutions of scientific thought feel about going along with the trend of digitizing everything, they know the potential of the Internet to promote their journals. Just about any journal that's worth its glossy cover has a web site with archives of their article abstracts. Abstracts are abundant on the Internet, and full text articles can be occasionally found.

Many signs point to changes coming up ahead. Budding Internet-only electronic journals such as the Electronic Journal of the Radiological Society of North America and Electronic Journal of Orthopedics are peer-reviewed journals based on the traditional print models. On-line versions of established publications are also showing up. Though most of the first comers to the digital age are of the low-profile variety of publications, some higher profile publications such as the British Medical Journal (BMJ) of the British Medical Association have decided that it's better to work with the changes rather than "fight the inevitable." [6] (At the previous revision of this paper, the BMJ allowed full-text access to many of its current and archived journals. This no longer appears to be true.) The New England Journal of Medicine's web site features an changing collection of full-text archives on featured topics in addition to access to the famed journal's abstracts.

Fear of losing subscriber base may play a key role in the decision to keep the already successful journals in off-line formats only, but the fear may be unfounded. Lem Lloyd, the new media director for the St. Paul Pioneer Press, was quoted in an Internet magazine saying "Most people, whenever they do anything on the Internet, like to print it out--which tells you something." [23] The unappealing aesthetic of electronic text is just one reason why printed text will always have a place. It's possible that the primary audience to digitized versions of most print journal publications are going to be students or non-research oriented members of the healthcare community who are more likely to hit the library's photocopier instead of subscribing anyway.

Certainly the publishers of journals do run a risk of losing subscribers if they make their material free on-line, but they also have a chance of gaining subscribers by showcasing their material. The WWW is often viewed upon as a to be avoided nebulous of free information that sucks away profit from print media. Rather, it would be more accurate to say that the WWW is a new form of media in its unstable adolescence and will eventually mature into new markets.

In an unfamiliar place, there's nothing like a familiar name. Amid all the warnings of questionable information on-line, there's the healthcare professional's old friend MEDLINE. Numerous options, Web based or otherwise, exist to access the MEDLINE database on-line. Some MEDLINE searches are free and some are available for a fee.

Free MEDLINE searches became popular in 1996 and numerous web sites now host a free MEDLINE search. Free searches were first seen as advertising gimmicks to draw traffic to web sites, but since the National Library of Medicine (NLM) in the US has begun offering PubMed and Internet Grateful Med for free, signs indicate that MEDLINE (free or for a fee) through the Internet can be a legitimate asset.

In general, the free MEDLINE services are inferior counterparts to the fee based services. [7] A systematic evaluation of a number of free MEDLINE services performed by one group in June of 1997 found that some services may have databases that are as much as seven weeks behind the better ones. [7] Currency of the database is really a minor issue. More important is that there are sharp and important differences between the interfaces (search engines) created by each service to retrieve relevant items from the MEDLINE database.

Good electronic information doesn't just make patients happy. It may help reduce costs by acting as a self-administered pre-screening by the patient and improve proper utilization of healthcare services.

The search engine programmed for each site to access the MEDLINE database is the most important piece of a MEDLINE search and unfortunately also the most inconsistent. Some engines will perform "fuzzy logic" searches and find related articles. Some have advanced search options that allow fine tuning of a search to increase the relevance of returned materials. Some are simple to use but so stripped down that they're no longer useful for purposeful research. A few (such as the NLH's Internet Grateful Med and Ovid) even cross reference terms with the MeSH database, a "subject thesaurus" that can be used to find information related to the search term. [7, 49]

Wide variations exist in number and relevancy of returned information. During the systematic evaluations performed in 1997 as mentioned above, the number of returned articles averaged 7 to 8 with a low of 2 and a high of 14. [7] Either some of the search engines are pulling in irrelevant citations, not finding more obscure citations, or both. Free does not necessarily mean "bad" with MEDLINE search services, but the fee based services are in general, better and also faster.

In addition to allowing searching, some of the MEDLINE search services also offer full-text delivery through the mail for a fee. The Loansome Doc program [49] of the NLM's Internet Grateful Med is one such service. Select articles, such as some of the citations featured in the NLM's PubMed service, can even be accessed full-text for free.

Also, as of September 1996, the National Library of Medicine released an on-line PRE-MEDLINE search, allowing users to search MEDLINE pre-print citations and abstracts that have not yet undergone the rigors of review. [49] Though PRE-MEDLINE articles have not yet been given the assurance of quality checks, information contained in them may be useful for members of the research community who could benefit from the new information immediately.

A growing number of medical texts are either available on-line or in electronic form in CD-ROM or other formats. One such textbook that is available on CD-ROM and on-line is the popular Merck Manual. Another on-line textbook is Wheeless' Textbook of Orthopedics, which few if any electronic textbooks currently on-line can match in content and user friendliness. One look at Wheeless' work is an insight into how the Internet can benefit clinical medicine.

Wheeless' textbook, which started quietly enough as a one man effort that provided quality, but limited content, has in one year matured into a co-authored advertiser supported multimedia resource with content categories ranging from basic orthopedics to prescription medications to operating procedures. Wheeless himself summarizes some advantages of using the Internet to publish his textbook:

The hypertext format allows the reader the most efficient path to the desired information. Further, textbooks can only be updated every few years and are terribly expensive. In contrast, the Internet has given me the ability to write a book that can be accessed by people in every country of the world, and yet I am under no constraints from a publishing company. [58]

As effective as the hypertext format mentioned by Dr. Wheeless is, it's not likely that mainstream publishers will be rushing to publish fully digitized versions of their new textbooks, but some are beginning to make the most out of both mediums by combining the convenience of the printed volume and the flexibility of the Internet. Oxford University Press is one such publisher. Owners of their Oxford Handbook of Clinical Medicine, and Oxford Handbook of Clinical Specialties can access electronic updates and supplementary information to complement their hardcopy prints. By creating a medical text with an open end, the clinical shelf life of a text book could potentially be extended by years. [31]

In addition to textbook type information, there is a growing resource of clinical reference books such as the Physician's Desk Reference. The on-line version of the PDR is free for qualifying physicians and available for a subscription charge to other health professionals and the public. Unlike the print version, the on-line PDR can go anywhere you go so long as you can get your hands on a keyboard and a modem. Another example of an Internet reference is the Internet Drug Interaction Database, which allows users to enter names of drugs to search for interaction effects or to enter individual drugs to obtain a listing of all interacting drugs. Now with the availability of powerful personal digital assistants such as the Internet ready 162Mhz Newton MessagePad, a card modem and a cellular phone will virtually allow the PDR and other on-line references to be carried in a pocket (albeit a large pocket).

On the supply side, keeping a complete stock of things like consumer information and industry bulletins can be very expensive. On the demand side, things like old press statements or reports may be needed on occasion, but either difficult to locate or a hassle to request through conventional means. The Food and Drug Administration of the US addressed both ends of the public information problem through the web and the Internet. Through use of the WWW, the FDA was simultaneously able to cut down printing and delivery costs while at the same time improving the availability of its wide range of consumer and provider information offerings. [26]

The FDA's website is structured into sections oriented to consumers, journalists, and healthcare professionals to better reach the populations that most frequently need it's publications. Every new publication that is put out by the FDA is immediately placed onto its website. Already in their Freedom of Information Act Electronic Reading room, there are indexes to warning letters, inspection operation manuals, monthly import detention lists, medical device reports, and other materials. [50]

For some purposes, the speed of delivery and currency that the Internet allows is very important. What's news today can be a problem tomorrow. E-mail is one way that some informational organizations can alert a specific audience quickly. Services such as the Intellihealth Professional Connect, sends daily editions of abbreviated medical news stories that can be accessed more completely on its web site. Reuters Health is another information service that provides daily news summaries on the WWW.

On the computer and technology front. Edupage is a periodic e-mail summary of all late breaking news in the fast moving industry of computer technology. In an industry such as computer technology where the news is happening so fast it's almost impossible to keep up, having the short summaries that services like Edupage brings is a very important asset for casual followers of developments in information and computer technology.

While the Internet may be still be lacking in the highly refined information sources that people doing concentrated research require (though it is changing slowly), it still opens doors for researchers to connect with many colleagues. One of the original purposes of the Internet was to allow people doing scientific research to network with each other [58] and many years later, the Internet is more than ever well suited for the needs of those seeking professional contacts. Some research scientists have already opened their works in progress on-line and invite private commentary or open discussion on their research. More scientists might open up their work to a community of their peers if the fear of plagiarism weren't so great. Plagiarism and blatant violations of copyright are strong representatives of the shadow side of our information technology. They are real threats and solutions are currently being sought to make seeking commentary on-line less of a professional danger. The issue of copyright and plagiarism will be discussed further in a following section.

Research scientists looking to perform questionnaire based studies may find collecting data from subjects on-line to be an economical way to conduct their surveys albeit impossible to generate a true random selection of subjects for their study. Members of the on-line clinical and research psychology fields have already begun to use the Net readily to perform surveys and gather data.

Sometimes the data that can be gathered on-line is not only easier to get, but may otherwise be difficult to obtain. One surgeon on an orthopedic surgery mailing list used his ability to quickly contact a large number of his peers to collect viewpoints and experiences with protective "space suits" used by surgeons during some operations to incorporate into his study on the usefulness of the suits. Many replies were returned publicly over the mailing list for all to view and may have encouraged otherwise non-responders to give their input. Through a trickle down type of effect, electronic forums (especially in long discussions) often have an ability to enrich total input by drawing in the comments of otherwise silent listeners. If you were to send a typed letter asking a large number of busy orthopedic surgeons about their experiences with a piece of equipment, how good of a response would you expect to get?

Reliable information can be found from many different kinds of sources on-line. Some health and medical information web sites are put up by individual medical professionals who posses a talent with computers such as the Running Injuries page of Dr. Pribuit. Some are an informational branch of efforts funded by grants or are the work of established information departments of teaching hospitals and educational institutions. Well informed and intelligent patients also can contribute valuable resources on-line.

Image of a sclerosed coronary artery from the WebPath: Internet Pathology Laboratories site.

Most major hospitals now have websites. Some of the better examples even contribute resource information such as case studies in an electronic archive of grand rounds for browsing. The University of Utah's WebPath: The Internet Pathology Laboratory keeps a large collection of pathological images taken from autopsy examinations along with explanations of stages or progression and objective findings as part of their educational curriculum. Brigham and Women's Hospital in Boston, MA and numerous other radiology centers around the country keep a library of radiographic teaching files of cases searchable by body part or imaging technique. The administrators of the Brigham Radiology site (BrighamRAD), view the WWW as a way of moving education back to more of a one-on-one level with the interactivity of the Web. One of BrighamRAD's rationales to providing case studies on-line was that shared teaching files for their medical residents would be of most benefit to them if they were always available and accessible on-line [21].

The source of on-line educational material may even come straight from the patients themselves. Especially the case with rare disorders, it's not uncommon to find websites created by well educated and informed patients who use the Internet to present their stories and knowledge of their disorders, hoping to generate awareness of their condition. [24] Through such websites the medical profession can achieve a deeper understanding of the human side of disease and become learners of privileged information that would never be found in a medical text.

Good information can come from a number of sources. Bad information, can come from even more. Hucksters trying to make dishonest money, poorly informed individuals, advertisers with an agenda, or people churning on the rumor mill can all create valid looking information resources. Misinformation on the consumer level is a concern of healthcare providers because it could result in harm or encourage unrealistic expectations of medical treatments.

With the popularity of the Internet growing on the healthcare front and concerns over the quality of information, there have been calls to develop standardized methods to evaluate the quality of on-line resources. Quality of information is not only a concern because of concerns over misinformation, but also to spare healthcare professionals the time and frustration of scanning through a promising looking site with completely sound, but useless information. To address the issue, a recent summit has gathered to develop an assessment tool for a medical website's quality [1] based on the following criteria:

• Credibility (source of info, context, currency, relevance, and peer review)
• Content (accuracy, hierarchy of evidence, original sources, disclaimer, omissions)
• Disclosure (purpose of site, profiling of the site's purpose and background)
• Links (selection, architecture, content, back linkages and description)
• Design (accessibility, organization, internal search engine)
• Interactivity (mechanism for feedback, chat rooms, tailoring of info)
• Caveats (alert information)

Some individual organizations such as Six Senses and Magellan already review rate health and medical websites, but by an unknown and sometimes questionable criteria.

In addition to efforts to establishing an evaluation criteria for quality, the American Medical Association and the American Telemedicine Association have urged individual medical specialty societies to develop electronic information standards for their own respective practice areas. [52] Future labeling of sites that meet established standards has been suggested as one solution to the problem, but the flexible nature of the web makes handing out seals of approval also a complicated issue. First of all, with the size and chaotic nature of the Internet, putting out a universally recognized seal of approval would be virtually impossible. [1] Also, because the Web is a dynamic environment, what is considered "good" today, may not be so tomorrow. This can be best illustrated by the great number of outdated websites that still display "best of the Net" type of awards from over a year past.

The issue over the quality of information has only recently been addressed. A practical solution is not likely to come about in the near future. Healthcare providers can best help their patients with on-line information by suggesting trusted link collections or providing links themselves. Teaching patients to be wary of super gurus who claim to be the ultimate authority on anything can help. Patients should also be made aware of literature databases from agencies such as the FDA in the United States that may have warning statements on some health and medical products.