Internet-based knowledge in medical practice. Should doctors be under professional obligation to search for information in each case ?

Piotr Kasztelowicz

Department of Tuberculosis and Pulmonary Diseases Ludwik Rydygier Hospital in Torun Medical Servers Team, Torun, Poland http://www.am.torun.pl

Internet Based Knowledge - Definition

Internet Based Knowledge (IBK) in Medical Practice

is a form of knowledge, supported by active search of medical information (from Internet), by use of internet resources. The core of this process is to select good quality and valuable sources, which can be used to improve patient management plan E-health in Common Europe Kraków 17-18 Dec, 2004 2

IBK and telemedicine

IBK originated from distance learning and can be considered to be a part of telemedicine. It is because a information obtained from an Internet is not only utilised for education, but directly included into diagnosis and therapy.

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Forms

 standard tools, which can be implemented to IBK (search engines, emails, mailing lists and usenet groups)  specialised resources (medical portals, closed medical mailing list and other dedicated tools)  Advanced forms of IBK - creation of Internet resources, allowing collection of information by medical research centres or practising physicians. This can evolve in Internet Based Research (if data were collected to perform study) or in telemedicine E-health in Common Europe Kraków 17-18 Dec, 2004 4

Internet Based Knowledge may be performed collectively, by the team of physician as common education form or to prepare more advanced education technology as Decision Support System (DDS) – described in paper V. Sintchenko et all –

Comparative Impact of Guidelines, Clinical Data, and Decision Support on Prescribing Decision: An Interactive Web Experiment with Stimulated Cases

– JAMIA, Jan/Febr 2004;11:71-77 E-health in Common Europe Kraków 17-18 Dec, 2004 5

Methods

 Resources Review   Search Methods * Open Search * Specialised Services Search E-mail as tool for IBK E-health in Common Europe Kraków 17-18 Dec, 2004 6

Review

     Systematically doing review known, good quality sources of information. Creating list of such sources, which should be reviewed each month, week or day.

If IBK is performed by the teams ,there should be an incentives to divide tasks into group of doctors, representing each speciality. There can be assembled local website with information prepared as news, summaries to share it for all physicians participating in collective IBK. known medical journals with high impact factor, selected medical portals with good quality and reputation may be underlined. E-health in Common Europe Kraków 17-18 Dec, 2004 7

Example of Review

recommended by A. S. Gosling et all –

“Clinical Team Functioning nad IT Innovation: A Study of the Diffusion of a Point-of care Online Evidence System

JAMIA May/Juni  Medline   Psychoinfo CINAHL  Healthstar 2003; 10,3: 244-251   38 full text journals (including JAMA, BMJ, NEJM) Harrison’s Online Book  Cochrane E-health in Common Europe Kraków 17-18 Dec, 2004 8

My Review List

 Proquest (http://proquest.umi.com)   Science Direct (http://vls.icm.edu.pl/ss.html) Medline (PubMed)  Medscape (

http://www.medscape.com)

 Docguide (

http://www.docguide.com)

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Search Methods

 

Open Search

– simple (using standard searching tools), high sensitivity be found), (most information having a word placing in query should less specificity – many spams, inappropriate and poor quality information (including advertising) will be listed. The strong verification and selection is necessary

Specialised Services Search

– using medical specialised services and built-in search system (for instance PubMed as Medline record search system) – excellent advertising resources) , specificity less sensitivity (but some can listed – editor decides which information will be listed many information, which left “out of” editor’s consideration or certification can be not listed. The strong verification and selection can be not necessary if service presents only good substantial quality of information E-health in Common Europe Kraków 17-18 Dec, 2004 10

E-mail as tool for IBK

 E-mail can be a good way to interchange private (with one person) or collective (using mailing list or usenet) messages.   As form of IBK e-mail can be used occasionally (to ask help with specific problem) or as continuos form (participating with discussion on mailing list or regular reviewing usenet groups). Mail can be used as an adjunct to completion of Resources Review and Search methods E-health in Common Europe Kraków 17-18 Dec, 2004 11

My four examples of Internet Based Knowledge in medical practice

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First - research

   This case was associated with research concerning PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Streptococci) My colleague, working in this center, asked me to find commercial reagent to test anti-DNAse B, which is important to confirm evidence of streptococcal infection Unfortunately no known commercial company producing medical laboratory tests can help to solve this problem E-health in Common Europe Kraków 17-18 Dec, 2004 13

Open Search

  open search method with Google search engine (

http://www.google.com

) and keys "

obsessive-compulsive

" AND "

Anti DNAse B

"

http://www.google.pl/search?as_q=%22obsessive compulsive%22&num=10&hl=pl&btnG=Szukaj+z+Google&as_epq =Anti+DNAse+B&as_oq=&as_eq=&lr=&as_ft=i&as_filetype=&as_q dr=all&as_occt=any&as_dt=i&as_sitesearch=

There was 64 links achieved, which was reviewed by me. Most interested seems to be article form Archives of General Psychiatry

Bradley S. Peterson et all Preliminary Findings of Antistreptococcal Antibody Titers and Basal Ganglia Volumes in Tic, Obsessive compulsive, and Attention-Deficit/Hyperactivity Disorders

(Vol. 57 No. 4, April 2000) present on page -

http://www.hypsos.ch/articles/strepto1.htm

.

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Searching

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Article

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I found desiderable information, that no commercial, valuable test is available in Poland.[

citation of expert – Prof. Edward Kaplan

“

We still use the DNA methyl green technique which was the original technique described by Wannamaker (who founded our laboratory) about 50 years ago. It is not commercially available. But we keep the test standardized and we are comfortable and confident with it “

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Scheme of Action

       Unsolved problem associated with recently planed research Attempts to contact (via Internet) with commercial companies to find commercial test Lack of positive answer from commercial companies Web Open Search Finding appropriate information and person Email to expert Detailed information how solve problem with recommendation how perform this test E-health in Common Europe Kraków 17-18 Dec, 2004 18

Schedule

    Search in web

27 th of May

Email sent to author – 27 th of May answer with advice to ask expert (with his email) –

27 th of May

Answer from expert –

28 th

data

of May

with preliminary Further email interchange to clarify details –

5 th of July

(after vacation time) E-health in Common Europe Kraków 17-18 Dec, 2004 19

Result

E-health in Common Europe Kraków 17-18 Dec, 2004 20

Second example - new drug

The second example was related with (admitted to Pulmonary Department) a patient with non-small lung cancer with multiple foci of brain metastases. The diagnosis was complicated, because primary tumour was not visible on standard chest X rays. The detailed diagnosis was made after stereotacitc brain biopsy by neurosurgeon. After histopathology was obtained chest CT have shown pulmonary tumour mass. Patient was clinically in very good condition. Member of his family was a MD. He said me about option to utilise new drug – gefinitib, if patient might be included to clinical trial with this drug, in one of Polish oncological centres E-health in Common Europe Kraków 17-18 Dec, 2004 21

Specialised Services Search

   The Specialised Services Search has been used – I was using MEDLINE by PubMed (

http://www.ncbi.nlm.nih.gov/entrez

/ ) – key “

gefitinib

”. 526 links to articles was found. 9 articles was chosen for further analysis. Most usefull information was in:

George R. Simon et all,

“

Gefitinib (ZD1839) in Previously Treated Advanced Non –Small Cell Lung Cancer: Experience From a Single Institution

”, Cancer Control” September/October 2003, Vol. 10, No.5 and

Federico Cappuzzo et all, “Epidermal growth factor receptor targeted therapy by ZD 1839 (Iressa) in patients with brain metastases from non small cell lung cancer(NSCLC)”, Lung Cancer

(2003) 41, 227-231 E-health in Common Europe Kraków 17-18 Dec, 2004 22

Searching

E-health in Common Europe Kraków 17-18 Dec, 2004 23

Article

E-health in Common Europe Kraków 17-18 Dec, 2004 24

Result

   After case analysis, using reviewed literature, we contacted oncological centre (first via email) and patient was consulted and included into the trial.

This case allowes us to continue co-operation and next similar, patient was included immediately into this type of therapy.

This case alowed us to demonstrate that IBK permits to do fast preliminary qualification and contact with remote referencing centre, to consult easier and eventually to manage, with new drug and therapy methods.

E-health in Common Europe Kraków 17-18 Dec, 2004 25

Scheme of Action

     Known case and entry information about possible new drug therapy (which and where) Specialised Services Search to achieve more information for preliminary referring to this therapy 526 link found, 9 analysed, 2 (two) most useful After preliminary positive qualification email contact to ask for consultation Patient was consulted and included into new therapy (clinical trials) E-health in Common Europe Kraków 17-18 Dec, 2004 26

Schedule

 Time frame : no more than two weeks till patient was treated E-health in Common Europe Kraków 17-18 Dec, 2004 27

Third example - poor condition of patient

   The problem was concerning a patient with sepsis after leg surgery caused from foot ischemia followed with Disseminated Intravascular Coagulation. The state of this patient was getting worse. Open Search Method using Google and one word query “

Disseminated Intravascular Coagulation

”.

There was 91200 answers.

http://www.google.pl/search?hl=pl&as_qdr=all&q=%22Diss eminated+Intravascular+Coagulation%22&lr=

E-health in Common Europe Kraków 17-18 Dec, 2004 28

Result

    After review most accurate links only one has bee chosen (this should enhanced complete short knowledge enabling to improve therapy – only one over time reason – patient was in worse condition and rapid decision should be taken) This one article was

Julie Hambleton, Lawrence L. Leung and Marcel Levi, “Coagulation: Consultative Hemostasis

” from Hematology available for all on Net under address

http://www.asheducationbook.org/cgi/content/full/2002/1/35

After getting information a plan of therapy would be changed, unfortunately patient died before including this changed to therapy - our therapy was planed correct. Despite this fact unfortunately patient died.

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Article

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Scheme of Action

    Open Search (Google) 91200 links but only analysis ( 1 (one) provided for further “less time to analyse more”) Changes were included into therapy, despite that patient expired The case was analysed to calculate outcome, if next similar case would be encountered E-health in Common Europe Kraków 17-18 Dec, 2004 31

 One day

Schedule

E-health in Common Europe Kraków 17-18 Dec, 2004 32

Fourth example - my own research

There is presented simple method to perform internet based study – “Tobacco-addition of internet users questionnaire”. The target of the study was to achieve information about tobacco habit and to present it on Anti-Tobacco conference in Poznan. Free cgi-bin software (BNBFORM-4.0 http://bignosebird.com/carchive/bnbform.shtml) was used at standard web-server APACHE and html-page form for data collection E-health in Common Europe Kraków 17-18 Dec, 2004 33

http://www.am.torun.pl/palenie

E-health in Common Europe Kraków 17-18 Dec, 2004 34

Number of smoked cigarettes

     below 10 – 16 10-25 – 14 16-20 –13 21-25 8 above 25 cigarettes – 9 poniżej 10 od10 do15 od16-do20 od21-do25 powyżej25 8 2 0 6 4 18 16 14 12 10 16 14 13 1 8 9 E-health in Common Europe Kraków 17-18 Dec, 2004 35

Targets

 The aim of study was not to carefully perform data analyzis, but only to perform simple, based upon open sources and free, technology.   There was no costs associated with this study. In this aspect project was successful In communities of “information age”, use of computing network as standard tool, to propagate health education by net, is very important E-health in Common Europe Kraków 17-18 Dec, 2004 36

IBK in medical practice - Discussion

The second part of title of my presentation search information in each case?“ is only a – question “. Should doctors be under Obligation to personal reflection . This is, of course in my opinion, not necessary to search information in each case. But I’m recording even today, that any barriers (psychological, sociological, related to limited usage of English or other languages) lead to impaired use of Internet sources to search for information related to management of patient.

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Barriers

  

This should be also paid attention to a better knowledge and English language skills by the doctor’s . English language courses should be available in every stage of postgraduate education. Many resources show that, without possesing English language , active usage of Internet Based Knowledge is practically impossible. Lack of sufficient language fluency can hinder using advantages of IBK.

Service http://freemedicaljournals.com/ shows shares different languages journals in world resources – the primacy of English is obvious

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Conclusions

   Improving general knowledge, availability to use Internet for Continuing Medical Education Efficacy of Search and Mailing options in practice and research “every day” Ability to join IBK with different form of telemedicine (including contacts with patients via email and by discussion on net) E-health in Common Europe Kraków 17-18 Dec, 2004 39

Conclusions (2)

   IBK is tool rather than separate idea.

It’s role is not to change a medical/professional methods, but to seek and obtain more information.This can improve patient care and faster solve problems with patient management care.

If any problems with a specific’s were met, Internet can be the best method to solve. Initially as “first line” method by using Search an Mailing methods.

Education how use IBK workshops, training programs - should be popularised . Improvement of English skills may be,in additon,necessary in medical education.

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