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

Internet-based knowledge in medical practice.

Should doctors be underprofessional obligation to search for

information in each case ?

Piotr Kasztelowicz <[email protected]>

Department of Tuberculosis and Pulmonary Diseases Ludwik Rydygier Hospital in Torun

Medical Servers Team, Torun, Poland

http://www.am.torun.pl

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

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Internet Based Knowledge - DefinitionInternet 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


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IBK and telemedicineIBK 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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FormsForms

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


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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


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MethodsMethods

Resources Review Search Methods

* Open Search * Specialised Services Search

E-mail as tool for IBK


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ReviewReview

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.


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Example of ReviewExample of Reviewrecommended 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 2003; 10,3: 244-251 MedlineMedline PsychoinfoPsychoinfo CINAHL Healthstar

38 full text journals (including JAMA, BMJ, NEJM)

Harrison’s Online Book Cochrane


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My Review ListMy Review List

Proquest (http://proquest.umi.com)Proquest (http://proquest.umi.com) Science Direct (http://vls.icm.edu.pl/ss.html)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 MethodsSearch Methods

Open SearchOpen Search – simple (using standard searching tools), – simple (using standard searching tools), high high sensitivitysensitivity (most information having a word placing in query should (most information having a word placing in query should be found), be found), less specificityless specificity – many spams, inappropriate and poor – many spams, inappropriate and poor quality information (including advertising) will be listed. The strong quality information (including advertising) will be listed. The strong verification and selection is necessaryverification 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 specificity (but some can listed advertising resources) , less sensitivity – 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


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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


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My four examples of Internet Based Knowledge in medical practice


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First - researchFirst - 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


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Open SearchOpen 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_qdr=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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SearchingSearching


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ArticleArticle


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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 ActionScheme 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


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ScheduleSchedule

Search in web Search in web 2727thth of May of May Email sent to author – 27Email sent to author – 27thth of May answer with of May answer with

advice to ask expert (with his email) – advice to ask expert (with his email) – 2727thth of May of May Answer from expert – Answer from expert – 2828thth of May of May with preliminary with preliminary

datadata Further email interchange to clarify details – Further email interchange to clarify details – 55thth of of

JulyJuly (after vacation time) (after vacation time)


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ResultResult


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Second example - new drugSecond 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


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Specialised Services SearchSpecialised 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


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SearchingSearching


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ArticleArticle


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ResultResult

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.


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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)


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ScheduleSchedule

Time frame : no more than two weeks till patient was treated


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Third example - poor condition of patientThird 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=%22Disseminated+Intravascular+Coagulation%22&lr=


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ResultResult

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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ArticleArticle


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Open Search (Google)Open Search (Google) 91200 91200 links but only links but only 11 (one) provided for further (one) provided for further

analysis ( “less time to analyse more”)analysis ( “less time to analyse more”) Changes were included into therapy, despite that Changes were included into therapy, despite that

patient expiredpatient expired The case was analysed to calculate outcome, if next The case was analysed to calculate outcome, if next

similar case would be encounteredsimilar case would be encountered


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ScheduleSchedule

One dayOne day


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Fourth example - my own researchFourth 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


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


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Number of smoked cigarettes

below 10 – 16below 10 – 16 10-25 – 1410-25 – 14 16-20 –1316-20 –13 21-25 821-25 8 above 25 cigarettes – 9

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1413

89

0

2

4

6

8

10

12

14

16

18

1

poniżej 10

od10 do15

od16-do20

od21-do25

powyżej25


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TargetsTargets

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


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IBK in medical practice - DiscussionIBK in medical practice - Discussion

The second part of title of my presentation – question “. Should doctors be under Obligation to search information in each case?“ is only a 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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BarriersBarriers

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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ConclusionsConclusions

Improving general knowledge, availability to use Improving general knowledge, availability to use Internet for Continuing Medical EducationInternet for Continuing Medical Education

Efficacy of Search and Mailing options in “every day” Efficacy of Search and Mailing options in “every day” practice and researchpractice and research

Ability to join IBK with different form of telemedicine Ability to join IBK with different form of telemedicine (including contacts with patients via email and by (including contacts with patients via email and by discussion on net)discussion on net)


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Conclusions (2)Conclusions (2)

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

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

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


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Documents

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