Health Informatics for the Primary Care Physician
Health Informatics for the Primary Care Physician
Authors: William F. Perry, MA, RN, Clinical Information Specialist, Kettering Medical Center Network, Kettering, Ohio; and Jane C. Buch, MLS, Medical Library Manager, Kettering Medical Center Network, Kettering, Ohio.
Peer Reviewers: Bonnie I. Chi-Lum, MD, MPH, Editor-in-Chief, American Medical Association web site, Loma Linda, Calif.; and Robert C. McKinstry III, MD, PhD, Assistant Professor, Neuroradiology Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Mo.
Editor’s Note—Health informatics is the practice of managing health care information with computers. Recording, storing, analyzing, and retrieving information to meet regulatory requirements, demonstrate quality improvement projects, and document complete patient care demands an ever increasing amount of physician time. This article will introduce the reader to computer-based practice management resources, the electronic medical record, e-mail, Internet resources, and security issues.
Computers are changing the face of primary care medicine. The electronic medical record can enhance a practice by improving legibility, improving documentation, and providing physicians with appropriate patient specific clinical reminders. Computers connected to the Internet offer the primary care practitioner an unprecedented opportunity for communication, collaboration, education, and research unhampered by the restrictions of time and distance.
Patients access many of the resources once primarily used by physicians. Health-related Internet sites appear and disappear rapidly. Consumers are inundated with ads urging them to visit drug-specific web sites and to ask their care providers if those drugs are appropriate for them. Patients are downloading information, emailing and chatting with others with similar symptoms, and bringing the results of their online investigations to their clinic appointments. If for no other reason, clinicians need to have an awareness of what is available to understand what their patients are reading.
Practice Management
Appointments, scheduling, and billing represent a major task for computers in the office setting. Patient demographics and insurance information are essential pieces of information to bill for services. Electronic certification of insurance participation is a timesaver for the clinician and patient. Computer resources can save practitioners and their office staff time while improving legibility, completeness, and maximizing reimbursement.
Clinically oriented systems can provide practitioners with documentation reminders to adequately justify appropriate diagnoses and interventions. By including the Health Care Financing Administration (HCFA) guidelines, billing and coding modules have reduced undercoding in some practices by 25-33%.1 Plan-specific formularies may be available electronically. Prescriptions can be electronically written using an application such as eMD.com,2 appointments made with consultants, and tests/procedures scheduled. These activities can result in efficiencies in patient care and time savings for all involved.
Business to business services give the primary care office the ability to order supplies and equipment electronically. This "just in time" approach saves money by minimizing the need to keep larger supplies on hand. Payment for goods is done through a secure system, and because of 24-hour availability, limitations imposed by time and geography decrease in significance.
Components of the Clinical Record
Searching for records, documenting care given, and providing copies of required documents takes time. An electronic medical record makes information available to whoever needs it, whenever they need it. In a multi-office practice, records do not have to be transported between offices, requests for information do not have to wait until the paper record is retrieved, forms do not have to be manually filed, and information duplication can be eliminated. Wireless technologies are being applied to the medical record with definite bottom line savings,3 and patients are accepting computers in the exam room as a matter of routine. Physicians do not need to be tied to the office to complete or review records. Given the appropriate user identification and passwords, records can be viewed and worked on from any computer attached to the Internet, whether from home or a vacation hotel room.
In a summary of a 1998 Lancet panel, 12 advantages were noted to an electronic medical record:4
1. Simultaneous, remote access to patient data
2. Legibility of record
3. Safer data—protection from lost paper
4. Patient data confidentiality
5. Flexible data layout
6. Integration with other information resources
7. Incorporation of electronic data (electronic testing and recording equipment)
8. Continuous data processing (subject to user defined rules, interaction, and alerts criteria)
9. Assisted search
10. Greater range of data output modalities
11. Tailored paper output
12. Always up to date5
Approaches to an electronic medical record vary from complete systems for large, multisite and multiprovider practices to single physician offices. In the single provider office, systems can range from integrated clinical and administrative systems to a single-user clinical application. Some physicians have chosen to automate portions of their current practices for such tasks as creating forms for frequently used documents such as physicals and insurance forms. While not the computerized medical record per se, applications to process routine tasks such as form completion greatly enhance office productivity.6
Connected computers that share information form networks. Networks may consist of as few as two computers connected by a cable to millions of computers connected to the Internet. There are many small-office networking kits available that allow all the computers in an office or business to share information with each other. If an office is networked, data can be entered from any computer attached to the network whether in the physician’s office or the exam room.
A relatively new approach to the electronic medical record involves an "application service provider" (ASP). Rather than purchasing the software, programs are leased and the vendor maintains the programs on their central computers. Information is entered into the systems using either a dedicated communications line or an Internet connection. With this method, savings are realized by outsourcing the technology component. The practice does not have to house the medical record software and the ASP takes care of hardware, security, and maintenance issues (such as backups), and patient copies of the medical record can be easily created. The patient medical record is password protected and can be viewed from any computer attached to the Internet. MedicaLogic offers a free trial of this approach.7 As fast Internet connections using ISDN telephone lines, DSL connections, and cable modems become more readily available, the ASP model will be as efficient and responsive as an application housed within a local facility.
Patients are becoming more interested in having virtual copies of their health record. Services such as PersonalMD offer consumers the ability to create an online health record, which includes both text information and faxed documents such as EKGs, radiology, and lab reports.8 The basic service is free to the consumer and any provider who has a need to see the recorded information; advertising and selling other value-added services supports the site. Access is via a secure Internet page and protected by a personal identification number (PIN). If a provider who does not have an Internet connection requires access to the information, a copy of the information can be automatically faxed to the requesting physician. If the patient’s primary care physician assumes an active role in supplying information for this virtual patients’ owned and oriented record, the benefits to the patient in an emergency situation could be life saving.
An evolving area in computerized health care information is where patients become participants in the documentation process by recording weights, medications taken, or transmitting information that originates from home monitoring devices. The health care provider reviews patient-transmitted information and appropriate interventions can be instituted early before they require vigorous intervention and hospitalization.
There are many vendors who supply the components to an electronic medical record. Prices and sophistication range considerably; the primary care practitioner who is contemplating an electronic approach can get an overview of various capabilities from such journals as MD Computing9 or Healthcare-Informatics.10 Single-user versions of a computerized record can be downloaded from such sites as PowerMed11 or SOAPware.12
The electronic medical record is becoming an essential tool. Sooner or later it will touch your practice.
Security Issues and the Computerized Medical Record
The conveniences and efficiencies of computerized tools in health care are complicated by the threat of viruses and the need to protect patient information. Any computer system is vulnerable to unauthorized access and the most elaborate security system is only as effective as the least compliant user. The confidentiality of patients’ electronic records is directly dependent on the security policies, procedures, and practices of the people using the system. Information becomes unprotected when passwords are shared, authorized users fail to log off a system when they are done using it, computers are left physically unprotected, or network safeguards such as firewalls are not implemented.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) proposes standardized approaches to the identification, transmission, storage, and security of electronic patient health care information. While still not finally released, any provider who stores patient information electronically will be affected. If a practitioner uses electronic mail to communicate with patients about health care issues, the e-mail files must also be protected. A list of suggested actions to prepare for implementation of these standards is on the American Academy of Family Practitioner’s web site.13 The proposed regulation and comments are posted on the Health and Human Services web site.14
Viruses are computer programs intentionally designed to cause damage to a computer or its resources. Viruses can be hidden in files downloaded from the Internet, from diskettes that have been used in an infected computer, or attached to e-mail messages. E-mail messages from unknown individuals, especially if they have attachments, should be deleted without opening them. Virus checking software should be installed on all computers. Trial software can be obtained safely from sources such as Symantec15 or McAfee.16 Comparisons between software packages can be made through web sites such as ZDNet17 or Cnet.18 The best way to protect a computer from viruses is to not allow anyone to run any software that is not a part of the office system.
In addition to good security practices, data must be backed up regularly to protect against electronic catastrophe. This is most often accomplished using tape backup systems or storing the files on CD-ROM. Internet-based storage is also becoming a popular way to store copies of electronic records away from the practice site. In the ASP model, the program vendor takes care of this function. In a locally housed system, it becomes a duty of the office staff. Even backups must be appropriately protected from unauthorized access.
Electronically Mediated Communication
In addition to the clinical record, the Internet-connected practice can expand communication with patients by allowing electronic mail requests for nonurgent clinical questions, appointments, and prescription refills. A practice web site can be a portal for these and other services such as patient education materials tailored to practitioner preferences. A 1999 Internet survey reported "the total number of health users"—those using the Internet for retrieval of health and medical information—as 24.8 million. Fifty percent of online users expressed interest in electronic communication with their physician or availability of information from their physician’s web site.19
In 1998, The American Medical Informatics Association developed "Guidelines for the Clinical Use of Electronic Mail with Patients."20 This document addressed concerns of clinicians regarding the medico-legal implications of such approaches and offers a set of protocols for the implementation of e-mail communication with patients. A successful approach to electronic communication begins with a documented agreement between the patient and their provider as to the services that may be requested, the types of problems that may be discussed, and the expected response time. In addition, it is critical there be the understanding that e-mail is a patient-provider interaction and is recorded in their medical record.
Electronic mail is not encrypted as a matter of routine and can be intercepted and read by anyone with the technical knowledge and equipment. In light of government regulations concerning the privacy of personal health care information, physicians must be very cautious when using unencrypted electronic mail. Encryption technologies exist, are available, and some are relatively inexpensive. A free, publicly available version of the encryption program Pretty Good Privacy (PGP) is available.21 While relatively simple to use, they may prove difficult for patients who are using services such as America On Line to access the Internet. Secure e-mail services such as those provided by Salu.net22 or Healinx23 are user-friendly ways to provide security for physician-patient communications. A signed statement by the patient and provider waiving the requirement for secure electronic mail should be considered if a secure e-mail system is not available to both parties. Practical considerations and concerns regarding the use of e-mail and patients are outlined at the Informatics Review web site.24
Electronic mail from patients must be protected in the same manner as paper-based patient information. Administrative considerations include assigning the responsibility to triage e-mail, office protocols as to the review and filing of electronic communications, and assuring the confidentiality of electronic documents.
The Primary Care Practice Web Site
Given the number of health care consumers who use the Internet to search for health care information, a web site becomes a potential gateway for present and future patients to find, learn about, and interact with health care professionals. Internet web sites range from simple to complex and from free to tremendously expensive.
Information on a practice web site might include basic information about a practice such as physician names, office hours, location, telephone, and fax numbers. Internet-based maps such as MapBlast25 or Expedia26 can provide door to door directions for new or potential patients. Photographs of the staff and of the office building aid in personalizing the web site. Submitting the practice web site to various Internet search engines or linking with local hospital or city web sites becomes a marketing activity that expands practice exposure.
Expanded web site offerings could include e-mail links, patient education materials, survey forms, newsletters, or appointment request forms. Reminders or special announcements could be sent by electronic mail. Many types of patient-provider or patient-office staff interactions that currently occur via the telephone could potentially be replicated in a digital format, extending the potential number of clients.
Professional Collaboration
Collaboration, discussion, and other information exchange occurs constantly between health care professionals. Few, if any, practice in a state of professional isolation, but they may be limited in their opportunities for interaction with other physicians because of geographic location, practice responsibilities, or other time constraints. Internet-based discussion with professional peer groups can offer a means to a broader viewpoint on practice issues.
Professional organizations frequently have a web site that incorporates web-based discussion areas to facilitate professional communication and collaboration. One of the best resources to find peer discussion groups is located at the Medical Matrix web site.27
There are two kinds of computerized discussion areas: mailing lists, also frequently called listserves, and web-based discussion groups. Electronic communication can be synchronous, where both parties are connected to a site simultaneously such as a chat room, or asynchronous, where participants read the messages left by other group members at a time of their own choosing. The advantage of the listserv or web discussion group approach is the independence from time and place requirements. Professional communities exist for both forms of asynchronous group discussion and have been shown to be a viable method of professional communication and collaboration. E-mail or web-based discussions replicate informal conversations between practitioners centered on a common clinical topic or clinical specialty. Anyone is free to initiate a message thread, and the number of responses to the topic posted is limited only by the interest expressed by the readers. Posting, or sending an e-mail, is not a requirement to remain in the group. As in any conversational group, some prefer to listen while others do most of the talking.
In a mailing list, each member of the list receives copies of any message posted to the list membership. Messages a subscriber receives from a list membership can either be delivered singly or bundled together and delivered as a single message called a digest. Other commands can be sent to hold mail messages while the member is on vacation. Some e-mail lists generate a tremendous volume of e-mail messages. If ignored, they will continue to be delivered to the subscriber’s electronic mailbox until the limit of the mailbox is reached and no other messages will be accepted.
In a discussion board, people wishing to read the posted messages go to the Internet site where the messages can be read as desired. No messages are delivered by electronic mail.
Continuing Medical Education
Continuing medical education opportunities abound on the Internet. Anytime, anywhere training is available to any practitioner with a computer and modem. Although electronically mediated CME lacks the personal interaction of a live professional meeting, the convenience of such approaches is drawing large numbers of practitioners. At some sites, interactivity may be encouraged making discussion boards available for participants.
Both fee based and free CME offerings are available. CMEweb.com offers more than 1100 hours in many areas of clinical interest, including internal medicine and primary care. Pharmaceutical manufacturers, hospitals, or medical schools and residency programs may sponsor free CME such as Helix.28 Medscape offers a combination of free and fee based CME.29
Research
Even before the advent of a graphical interface (the World Wide Web), physicians with strong information technology backgrounds were using the Internet to gain access to research, especially that which was unpublished or not yet published. Often the search process involved hours of scrolling through menu screens without ever finding a primary source. Today the Internet offers a wide array of accessible resources for physicians. In fact, there are so many resources that physicians face a new problem: sifting through an overabundance of sites in an effort to distinguish trash from treasure.
PubMed30
One of the undisputed treasures on the Internet is PubMed, the National Library of Medicine’s site for searching Medline and related databases. PubMed offers free access to anyone on the Internet. Technical support is available via e-mail or a toll-free number (800-338-7657).
Basic Search Techniques
Basic Searches are a good solution for searchers who are inexperienced, in a hurry, or who aren’t getting any results with advanced search strategies.
Basic Search Steps
1. At the PubMed home page, type your search terms in the query box at the top of the page. Use uppercase for Boolean connectors: AND, OR, NOT.
2. Press the Enter key or click the Go button.
3. After a few seconds, the results of your search will be displayed.
Displays
1. The default for search results is a summary (citation) display of 20 items.
2. Click on the author’s name to view the citation and abstract; use your browser’s Back button to return to the list of citations.
3. To change the display on the results page, click on the drop down box next to the Display button and choose an alternate format, then click the Display button. The most commonly used formats are:
• Abstract: includes citation and abstract
• Citation: includes citation, abstract, and Medical Subject Headings
• Link out: includes an abbreviated citation and link to the journal web site when available
4. To change the number of items displayed on a single web page, click on the drop down box below the Display button, choose a different number, and click the Display button. It is sometimes easier to navigate with all the items displayed on one page rather than paging through the results.
Selecting Items, Using the Clipboard, and Printing
1. There is a selection box to the left of each citation, no matter which display format you are using. When you click in this box to select the item, a check mark appears. To deselect the item, click in the box again and the check mark will disappear.
2. To save items to the clipboard, click on the Add to Clipboard button at any time in the selection process. Duplicate items are never added. If no selection boxes are marked, all of the items in the results (not just the items on the page) are added to the clipboard. Up to 500 items can be placed on the clipboard. They will remain there until they are deleted or until an hour has passed with no activity. This allows you to try as many search strategies as you like before printing.
3. To print selected items, click on the Clipboard link below the query box. On the clipboard page, choose the display format you want to print and click on your browser’s Print button.
4. Before going onto a new search topic, it’s a good idea to clear the clipboard by clicking on the Remove from Clipboard button. If no items are selected, all the items will be cleared.
Advanced Search Techniques
Limits are a useful way to narrow the search when the retrieval is too large.
1. Click on the Limits link below the query box.
2. The limits page allows you to limit your search by:
• common publication types;
• language;
• age groups;
• human or animal studies;
• gender;
• publication date;
• entrez date (the date the article was entered into the database); and
• journal subsets such as Abridged Index Medicus, Nursing, Dental, PreMedline, and Publisher Supplied Citations.
Medical Subject Headings are Often the Starting Point for Experienced Searchers
1. Click on Mesh Browser link on the blue bar on the left side of the home page.
2. Enter your first topic in the query box and Mesh Browser will try to identify a Medical Subject Heading related to it. For example, if you type "liver cancer," Mesh Browser will return the subject heading "liver neoplasms." If Browser can’t map to an exact subject heading it will give you a list of headings from which to choose.
3. A definition of the term is usually displayed below the subject heading. Below that is an index section showing where the term fits into the subject heading scheme. At this point, you may click on a broader or narrower subject heading. Always remember to choose the narrowest or most specific subject heading appropriate to your topic when starting a search. For example, if you are more interested in liver cell adenoma than liver cancer in general, use that term rather than liver neoplasms.
4. Returning to the top of the screen, click on the Detailed Display link next to the subject heading. This will take you to the subheadings screen. Clicking on subheadings such as "diagnosis" or "drug therapy" will help you to further define your search. You may choose as many as you want; they will be OR’d together.
5. Detailed Display offers two further options:
• Click in the box next to "Restrict Search to Major Topic headings only" when the subject heading you have chosen should be a major point of the article.
• Click in the box next to "Do Not Explode this term" when you do not want narrower terms included in the search. For example, you want articles on liver cancer in general but not just on liver cell adenoma.
6. Click on the Add button to add your term to the search. A box will appear which contains your search strategy. At this point you may enter an intersecting term in the query box to add to the search strategy, or you may click on the PubMed Search button to complete the search.
Details
The Details button appears on any page with search results, in the array at the top of the page. A link to Details also appears whenever a search strategy fails to produce any results. Click on it to see how PubMed has interpreted your search strategy and to edit your search strategy. If you have entered your search in plain text, this feature will show you whether PubMed has mapped it to a subject heading. If your search results are too broad, you can change your subject delimiter from "MeSH Terms" to "MAJR" for Major Topic headings. If your search results are too narrow, you can use the details dialog box to do the reverse. You can also add terms or delete them.
PreMedline and Publisher Supplied Records
PreMedline records are citations that are so new they have not been completely processed. They usually don’t include Medical Subject Headings. Publisher supplied records are citations that the National Library of Medicine includes only because the publisher supplies the information. These citations will never be assigned Medical Subject Headings. A search strategy that relies solely on Medical Subject Headings will exclude these citations, which often represent the newest information on a given topic. To make sure that PreMedline and Publisher Supplied records are included in your search, add terms with no qualifiers or with a [textword] qualifier to your strategy. For example: measles [MAJR] OR measles.
Other Features
Clinical Queries uses built-in research filters to help you find clinically sound studies. The link to Clinical Queries is on the blue bar on the left side of the home page. On the Clinical Queries page, enter your search term(s) in the query box and click on one of these four categories: therapy, diagnosis, etiology, or prognosis. Then choose to emphasize either sensitivity or specificity and click on the Go button.
Citation Matcher aids you in completing partial citations. Click on the Single Citation Matcher link on the blue bar on the left side of the home page. Fill in as much of the citation as you know. You must use the full title of the journal unless you know the Medline abbreviation (which you can find using the Journal Browser link). PubMed will return any citations that match the information you input. You can use this feature to browse the contents of a journal issue by searching the journal title and volume/issue or date.
URL and Cubby are two separate functions, both of which allow you to save a search strategy. The URL function saves your search by bookmarking it. When you are satisfied that your strategy is producing the results you want, click on the details button and remove any publication date or entrez date references. Then click on the URL button below the dialog box. This will return you to the results page, but now the search strategy is embedded in the URL or web address. Use your browser’s bookmark feature to bookmark the page. Every time you click on the bookmark, your search will be updated and run. With the new Cubby feature, you simply click on the Cubby link when your search is complete and name the search when prompted by PubMed. When you are ready to run the search again, go back to the Cubby link and click on the search name. The Cubby feature does require a brief, free registration and a log-in each time you use it.
Other Useful Sites
Clinical Trials
CenterWatch Clinical Trials is a division of the Medical Economics Company, publisher of Physicians’ Desk Reference.31 The site provides:
• a list of clinical trials arranged by disease category that gives brief information about the trials and a form to request further information;
• information on NIH studies;
• a clinical trial notification service; and
• information on newly approved drug therapies.
ClinicalTrials.gov, a new site sponsored by the NIH through the National Library of Medicine, allows users to search clinical trials using keywords or browse by disease/condition or sponsor.32 The site provides information of the purpose of and eligibility for the studies, contact information, and a link to further information when it is available. There are also links to detailed information about participating in clinical trials.
Practice Guidelines
National Guideline Clearinghouse33 is sponsored by the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research), the American Medical Association, and the American Association of Health Plans. The site expands on the AHCPR site for locating practice guidelines. In addition to keyword searches, the user may browse by disease/condition, treatment/intervention, or organization. Viewing formats include brief summary, full summary, and full text. A special feature of the Clearinghouse is the option to select guidelines and compare them in terms of adaptation, length, developer(s), funding source, committee, group composition, disease/condition, category, clinical specialty, intended users, objectives, target population, review methods, endorsers, outcomes considered, cost analysis, methods to collect evidence, methods to assess the quality and strength of the evidence, methods to analyze evidence, and availability of full text.
Instructions to Authors
Raymon H. Mulford Library of the Medical College Of Ohio hosts this page of links to more than 3000 journals in the health and life sciences that provide instructions to authors on the web.34 Arrangement is alphabetical by journal title.
Drug Information
Gold Standard Multimedia’s Clinical Pharmacology Online, previously a propriety product, is now available for free (registration is required).35 This is the full product version and includes information on prescription, OTC, and investigational drugs; herbal products; drug photographs and product identification; drug interactions; and patient education.
The FDA Center for Drug Evaluation and Research’s Drug Information page, updated daily, is a good resource for drug news, especially concerning recently approved drugs.36 The link to New Drugs Approved for Cancer indications provides timely information on this rapidly changing topic.
Full Text Books
The Merck Manual of Diagnosis and Therapy37 allows the user to do a keyword search or browse the table of contents of this core medical text.
Lexi-Comp’s Diagnostic Procedures Handbook is part of the HealthGate site, one of the established medical malls on the Internet.38 Entry is by keyword search or alphabetical index. This is a quick reference guide for diagnostic procedures that may include a section on what the procedure commonly includes, indications, contraindications, patient preparation, special instructions, equipment, technique, causes for rejection, turnaround time, normal findings, critical values, limitations, and references.
University of Iowa Family Practice Handbook is found on University of Iowa’s Virtual Hospital site.39 It is searchable by keyword or hyperlinked table of contents. The text is presented in outline form with hyperlinks to "see" references.
Virtual Hospital’s Multimedia Textbooks offer electronic texts on a wide variety of topics.40 As the name implies, these textbooks include graphics and sounds.
Full Text Journals
Brandon/Hill List of Journals is a National Library of Medicine site based on the "Brandon/Hill Selected List Of Books And Journals For The Small Medical Library."41 A table lists all of the Brandon/Hill journals and indicates whether full text is available for each title and, if so, whether it is fee-based or free. Where full text is not an option, there is information on the availability of abstracts. Finally, the site provides start dates for online access.
MedWeb from Emory University lists more than 700 electronic medical journals.42 There is no quick way to navigate through the alphabetic listing, but you can browse by subject or do a keyword search. The information offered about each journal is inconsistent; it may include a note on the publisher, a brief scope note, or full text options. Cost information is included for each title. Go to the Advanced Search and type "free" in the query box to get a list of titles that are offered gratis.
Patient Education
Clifford Stoll, noted computer security expert, wrote "Silicon Snake Oil" in 1996. Anyone who has spent any time searching the Internet for any type of information is confronted with an overwhelming number of choices in response to their queries. The dynamic nature of the Internet allows instantaneous publishing with a potential audience of millions. There is no censorship, quality assurance, or regulation of Internet resources.
The Miretek Organization, a nonprofit technology organization, is the home of The Health Information Technology Institute whose mission is "to ensure quality health care by conducting research in support of accessible, affordable, and appropriate health care in the public interest."43 They have created an "Information Quality Tool," an online series of questions that helps users evaluate the content of a health care web site and returns a score based on the user’s responses.
The federal government has a large number of web sites directed to health care consumer education. Professional organizations compile lists of peer-reviewed sites for both health care professionals as well as consumers. The Health on the Net Foundation is a voluntary group started in 1994 in Switzerland that encourages web site owners to post its logo if they agree to abide by their Code of Conduct.44 The Code of Conduct is designed to make visitors to health care sites aware of that resource’s approach to health care information. The areas addressed are authority, complimentarity, confidentiality, attribution, justifiability, transparency of authorship, transparency of sponsorship, and honesty in advertising and editorial policy.
Consumer discussion groups, both listserv and web bulletin boards, are common. The value of online support groups is well documented.
Patient Information Web Sites
MEDLINEplus, sponsored by the National Library of Medicine, is a good starting place for patient information.45 It is not a primary source for disease/condition/procedure information, but it does provide links to excellent web resources. Users can do a keyword search or browse by topic. Pages are organized into two categories: government and other resources. Within those categories are such subgroupings as General/Overviews, Clinical Trials, Coping, Diagnosis/Symptoms, Pictures/Diagrams, Espanol/Spanish, Organizations, and Research. Nongovernment resources have been well-researched and evaluated. Other useful resources on MEDLINEplus include an illustrated medical encyclopedia, links to online medical dictionaries, and a guide to prescription and OTC drugs from the USP DI and Advice for the Patient.
The American Academy of Family Physicians’ Health Information for Patients page offers 200 patient information handouts originally published in American Family Physician.46 The AAFP Family Health & Medical Guide contains self-care flowcharts for common complaints.
Healthfinder contains an outstanding collection of consumer links that have been reviewed by federal librarians for accuracy and credibility.47
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38. Lexi-Comp Diagnostic Procedures Handbook. http://www.healthgate.com/dph/html/index.shtm
39. University of Iowa Family Practice Handbook. 3rd ed. http://www.vh.org/Providers/ClinRef/FPHandbook/FPContents.html
40. Virtual Hospital Multimedia Textbooks. http://www.vh.org/Providers/Textbooks/MultimediaTextbooks.html
41. Brandon/Hill List of Journals. http://www.nnlm.nlm.nih.gov/psr/outreach/branhill.html
43. The Health Information Technology Institute. http://hitiweb.mitretek.org
44. The Health on the Net Foundation. http://www.hon.ch
45. MEDLINEplus. http://www.nlm.nih.gov/medlineplus/
46. The American Academy of Family Physicians’ Health Information for Patients page. http://www.aafp.org/family/patient.html
47. Healthfinder. www.healthfinder.gov
Other Suggested Resources
• Amatayakul M. Critical success factors. Health Management Technology 2000;21(5):14-16.
• Borowitz S, Wyatt J. The Origin, content, and workload of e-mail consultations. JAMA 1998;280:1321-1324.
• Danny’s Clinical Use of Email (Electronic Patient Centered Communication) Page. http://clinical.caregroup.org/ePCC/
• Gruen J. The physician and the Internet—Observer or participant? MD Computing 1999;12(6):46-48.
• Jadad A, Gagliardi A. Rating health information on the Internet. JAMA 1998;279:611-614.
• Joch A. EMR the Web Way. E.MD Online. http://www.edotmd.com/s00/cover.htm
• Manteuffel T. Keeping e-mail secure for health care communication. Internet Health Care Magazine 2000;May/June:82-88.
• Noble S. PDAs and hand-helds: World without wires. Health Management Technology 2000;21(5):28-32.
• Spicer J. Practicing without paper. Family Practice Management 1999. http://www.aafp.org/fpm/990300fm/40.html
• Spielberg A. Oncall and online. JAMA 1998;280:1353-1359.
• Stevens L. Computer-based patient records. Medicine on the Net 1998;4(8):8-11.
• Tools for Your Visit to Your Doctor. http://www-med.stanford.edu/shs/smg/tools/index.html
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