Doctors are beginning to realise that the internet is their friend, not their foe, writes MICHAEL KELLY
THE DAYS when GPs kept patient information in manila folders were more or less consigned to the mists of time with the advent of computerised patient record systems. But a second wave of computerisation is seeing the internet become an increasingly important diagnostic and information tool for GPs during consultations.
The ability to utilise the internet is now an essential skill for GPs to learn, according to Dr Brian Meade who is the national IT training co-ordinator with the GPIT Group (a department of the Irish College of General Practitioners which promotes the usage of information technology among GPs).
“We believe that about 84 per cent of GPs are using PCs in surgery but the level of usage varies. It’s important to differentiate between GPs who use a PC for appointments and a GP who is using the internet during consultation.”
The internet can be a source of accurate, unbiased and up-to-date information if you know where to look for it, according to Dr John Cox, a GP in Fethard, Co Wexford. Some of the most useful sites, he says, are those that provide a very specific piece of information in an easily accessible manner.
“The Medical Council has a website where you can find contact details for other GPs. It’s a simple thing, but it’s very useful, for example, if you have a new patient who mentions another doctor’s name during consultation. You can very quickly get the doctor’s contact information and dictate a letter to them there and then if you need to.”
Another example he provides is the Irish Pharmaceutical Healthcare Association’s medicines compendium (www.medicines.ie) which lists product characteristics of medicines available in Ireland.
“If I type in Nexium, for example, it will give me an up-to-date summary of indications for that drug, and what doses to use for each. It also lists indications where it should not be used and the possible side effects. That puts you in a good position to answer specific questions that a patient might have.”
Doctors can also use the internet to print off (or e-mail) information leaflets for patients to help them to understand their condition.
“I had a lady in here recently with irritable bowel syndrome which is a condition where having the patient well informed is a large part of its management. I printed off the leaflet from www.patient.co.uk and went through it with her line by line. Before the internet we had a large box full of leaflets, most of which were provided by pharmaceutical companies, and of course they went out of date quickly.”
For information during consultation (particularly if a rare or unusual case presents itself), Cox typically uses GPnotebook which he says is concise, accurate and evidence-based.
He outlines a recent case where a patient’s blood test results revealed an elevated level of bilirubin (an excretion from the bile). “It is an isolated and unusual finding,” he says, “but there just happens to be a condition called Gilbert’s [pronounced Jeel-Bears] syndrome which elevated bilirubin can be an indicator of. I had the patient on the phone and I went to GPnotebook to find out about it. While I was doing that my patient had Googled the syndrome and he was reading back to me what it said about it. I said to him, ‘How on earth did you know that?’ and he replied ‘I can Google quicker than you can, Dr Cox.’”
This anecdote highlights an important point about the veracity of information available on different sites. In Cox’s case, he was accessing the information from a trusted medical site designed especially for doctors. If you Google Gilbert’s syndrome, on the other hand, the first entry returned is a Wikipedia page – and as we know there has been much debate about the veracity of information on Wikipedia.
According to Dr Kieran Murphy, a GP from Athea, Co Limerick, doctors should help their patients to differentiate between those websites which provide reliable health information and those which do not. The Health on the Net (HON) Foundation in Switzerland, he says, is a non-governmental organisation which assesses the information on medical websites for accuracy. “The HON site has a search facility which retrieves only websites which they have certified and if you come across a website that has the HON logo on it, then you know the information is accurate. Unfortunately, there are a lot of sites out there where there is no editorial control and the information on them is positively dangerous.”
Murphy uses a subscription-based site called Mentor (www.mentor-online.com) for diagnostic information. “That is the site I use primarily. I can access the information I need there quicker than anywhere else and it’s concise, precise and very specific.”
He also praises the VHI website and the Irish health portal, www.irishhealth.com.
According to GPIT’s Meade, travel information websites are also extremely useful because of how important it is to have the latest information on vaccinations. “You could have a patient sitting in front of you who is about to visit three separate African countries and a website like Travax will provide safe, correct and up-to-date information on what vaccinations are needed. You simply can not get that from a book.”
About 1,300 GPs in the Republic are now participating in Healthlink, a nationwide web-based communications project funded by the HSE.
The service allows GPs to access information about their patients, including lab and radiology results, AE attendance notifications, outpatient appointment updates and referral information.
In some cases, it also allows them to order blood tests online. The service is available free to GPs and can be linked directly in to the GP’s Patient Management System so that information about a patient is transferred to the patient’s electronic file.
Healthlink will be accessible to all GPs in the State by 2010, according to national project manager Gemma Garvan. Healthlink is not without its detractors, but Meade believes it allows for an efficient exchange of information between the primary and secondary healthcare systems.
“It has been a huge bonus for us because it has encouraged general practice to start using computers and the internet. It is a major time-saving bonus for GPs.”
Another emerging trend in internet use among GPs is online Continuing Medical Education (CME), where doctors use the internet to access learning modules and tutorials. The British Medical Journal’s CME website (BMJ Learning) provides more than 280 interactive learning modules for GPs. According to Meade, online CME is hugely beneficial to GPs, particularly those in remote areas.
“They can learn in their own time and in their own homes if they wish,” he says. “The modules typically last half an hour each. The content is usually very well produced with pictures and videos in some cases.
“At the end there is an assessment and if the doctor gets over 80 per cent, they get a certificate which in the UK they can use as proof of continuing professional development.
“At the moment in Ireland you can do all the education you want and it won’t count for anything but I believe that is about to change which is a very exciting development,” he says.
Some GPs, however, prefer the traditional approach to education. “The difficulty I have with online CME,” says Cox, “is that it is quite isolating. We get together for CME in Wexford and that form of it is very popular because you can talk to colleagues and bounce ideas off them. I think the online CME could benefit from more use of chat rooms to replicate that sense of camaraderie.”
The moral dilemma posed by medical information which is sponsored or provided by pharmaceutical companies has always been somewhat of a thorny issue for GPs – a similar issue arises with online information. The medical portal univadis, for example, which claims to have 400,000 users, is operated by pharmaceutical company MSD.
“Univadis is a portal and most GPs use it as a gateway to other sites where the content is trusted,” says Meade. “For example, I would use it to get to PubMed [US National Library of Medicine] or GPnotebook. Go to any education meeting for GPs in this country and you will find they are sponsored by pharmaceutical companies.
“If they weren’t, these meetings wouldn’t be happening at all. There are some difficulties with this obviously but I think that doctors are canny enough to restrict themselves to content that they know and trust.”
So what was life like for GPs before the internet?
“We had extensive libraries and we referred to them when we could,” says Murphy. “That meant that we would often have to get the patient back for a second or third consultation.
“So, ultimately, this is about better care and shorter diagnosis times for patients. I couldn’t work without it now. It would be like having one hand tied behind my back.”
Useful links
www.gpit.ie
www.icgp.ie
www.medicines.ie
www.medicalcouncil.ie
www.patient.co.uk
www.hon.ch
www.travax.nhs.uk
www.healthlink.ie
www.GPnotebook.co.uk
www.univadis.ie
www.pubmed.gov
www.mentor-online.com
Before using the internet for information during consultation, GPIT advises the following:
GPs should be proficient in the use of the computer and the internet.
Be aware of what information is available and get to know a few websites with useful information.
Bookmark sites that are useful.
Have web browser open on the desktop all the time.
Be clear what information you want before you search.
Explain to the patient what you are doing and involve them in the search if appropriate.
If you can't find what you want within three minutes, drop it and move on.
Print out useful information for the patient.
The General Practitioner Information Group is currently promoting the use of the internet by GPs but is also pushing the importance of data security which is particularly important when using the internet. For more information, see www.gpit.ie