JRSM >
Volume 96, Number 10 >
Pp. 490-493
Primary Care Informatics, Department of Community Health Sciences, Hunter Wing, St George's Hospital Medical School, London SW17 0RE, UK
E-mail: slusigna{at}sghms.ac.uk
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‘As a general practitioner piloting 21st century electronic links across the healthcare system, you get a thrill each time you send a prescription direct to the pharmacist. Then you find that, because pharmacists now telephone holders of uncashed prescriptions, your drugs bill is up by 20%. Equally, some of your patients send thoughtful emails, but you need nearly two hours a week to respond properly.’ — Wyatt and Keen1
Investment by the National Health Service (NHS) in internet infrastructure will open new opportunities for patients and clinicians. The initial funding was prompted by the 1998 report Information for Health,2 and an additional £500 million is promised over the next few years.3 Modernization of the infrastructure4 includes not only better access to information sources5-7 but also electronic transmission of prescriptions, electronic appointment booking and enhanced medical records. But how will patients and clinicians use the internet? The effects of this IT (information technology) revolution on practice and organization are not all predictable,8,9 as Wyatt and Keen indicated in the above quotation.1
In this review I look at how the internet is being used at present and try to identify emerging patterns. The paper is based on material obtained from a Medline search under the terms NHS AND Internet, Internet AND Outcomes AND UK, and Internet AND patient AND Information AND UK. This yielded 213 papers, in 47 of which the abstracts referred either to use of the internet in clinical care or to sites designed to improve the quality of care. The websites of the Department of Health and the NHS Information Authority were also searched with these terms. To obtain a consumer perspective, I used the Google and Yahoo search engines to identify the most popular websites.
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The three differ in design and lack any common indexing system or search mechanism; consequently the user will have difficulty in merging the resources they offer.
Outside the NHS there are few fixed structures, with the notable exception of those provided by the US National Library of Medicine (NLM). The NLM's range of biotechnology resources includes PubMed Medline, with its searchable archive of over 11 million journal citations, material on the genome and genetic disorders, and access to PubMed Central (online full-text access to over 100 journals). In addition, links to free medical journals are available via FreeMedicalJournals.com,11 which lists over 1000 journals, though for some the content is included only in part or two years after original publication.
There have also been attempts to offer guidance on the quality of health websites. One of the best known is Health-on-the-Net (HoN), which offers principles for assessing the sites; however, these are largely about the process whereby the content is assembled rather than the quality of individual parts. Despite many attempts, a single method for identifying and labelling sites with good-quality information has proved elusive.12
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From the evidence examined, only a minority of patients at present use the internet as their preferred information source on health, though in most surveys about half have internet access. Rokade et al.14 questioned ENT outpatients and found that only one-third of those with access had consulted the internet before attending; evidently, most still relied for information on their GP. Among patients attending a cognitive function clinic Larner15 found a higher level of internet use for health information (26%), and stressed the importance of asking what sites the patients were using, so as to help them with their search strategies. Similar messages have appeared in nursing journals: both Timons16 and Greenwood17 emphasize the contribution of such help to patient ‘empowerment’. Moreover, unless clinicians ask what information patients have already looked up, they are unlikely to find out. For example, a sizeable proportion of urology patients proved to be using ‘alternative’ remedies, having discovered about them from the internet; yet most had not told their urologist or GP.18 Among patients of paediatric outpatients, Tuffrey and Finlay19 found that 22% (nearly half of those with access) had looked for information on the internet. What they add is that 6% had had a health professional suggest the internet, and when this had happened the parents were three times more likely to use it. Of those who had consulted the internet before an appointment, all but a few found it useful. In other areas of paediatrics the proportions of parents consulting the internet are closely similar—chronic renal failure 23%,20 paediatric surgery 24%.21
What can be said of the sites themselves? Smart and Burling systematically reviewed the information available online for patients about radiology procedures.22 Their verdict was that the information was helpful but often incomplete; moreover, some of it would present difficulties for people of limited literacy. More encouraging results emerged from an exit survey of those who use the NHS Direct touch-screen kiosks: two-thirds said that the kiosks answered their questions, with only 16% feeling that they had more to ask.23 NHS Direct-on-line5 is indeed the only official NHS site that features in surveys of the top internet sites. It is joined among the top fifty (according to a commercial website rating company)24 by Patients UK.25 This is a collection of over 500 patient advice leaflets written by two GPs, distributed free via this site. The top UK health sites (listed in Internet Magazine,26 for example) are dominated by information sites, and have more to say on issues of health and fitness than about illnesses and medical disorders. A site that goes beyond information is NetDoctor;27 this offers interactive reminders on request to those taking oral contraceptives, as well as providing the opportunity to ask a doctor a question online. Another, Contact a Family,28 provides extensive information on a range of rare conditions and enables affected families to get in touch for mutual support.
Information source for professionals
In UK primary care, 69% of GPs and 70% of practice nurses use NHSnet and
the internet in their work. The main constraints are lack of time, lack of
skill and worries about reliability. Half are willing to recommend the
internet to
patients.29 But
often it is the patient who makes the first move. Most GPs have had patients
arrive for their appointment with information gathered from the internet, and
in many instances this information comes fresh to the GP. Also, the responses
of GPs are likely to differ. In one survey professionals within a single
practice reported different degrees of access to information
sources,30 and this
observation probably reflected varying competence rather than different
facilities. The sad fact is that some of the material will be of poor quality:
there is no easy way to completely avoid low-quality material, even for NHS
Direct-on-Line,31
though fortunately as yet there is no evidence that unrestricted consumer
access to health websites does
harm.32
How much does use of the internet change practice? There are data on how certain of the services are used—for example, toxicology information33 or the Primary Care National electronic Library for Health34—but there is scant evidence on the extent to which their use changes practice. Nevertheless, observations on the use of an internet resource can provide useful secondary information on the kind of information that is wanted. For instance, of 60 281 accesses to the product database of a toxicology site the greatest number (7291) were for paracetamol. Ecstasy was at number seven.35
Another facility offered by the internet is a form of open review, whereby users and potential users comment on what is proposed. McNulty et al. have reported the feedback that they received about antibiotic guidelines, and how they were able to improve these guidelines as a result.36 Whether the internet can be used as a medium for learning new ways of practising is more doubtful. Online educational materials are available,37,38 and online interactive internet workshops are claimed to be useful;39 those who produce electronic libraries have started to talk about them as knowledge services.40 However, just making things electronic is not the whole answer.41 If healthcare professionals are to learn and change, the human interactions demand attention.42 Powerful electronic technologies carry the risk of information overload, and those who wish to flourish in this new environment must develop a knowledge management strategy.43
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| Acknowledgments |
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