February 25, 2009
10 min read
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The internet has revolutionized patient care and practice

Instant access improves care but professionals must overcome misinformation that patients might find online.

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When a patient presented with a thyroid mass that turned out to be thyroid lymphoma upon further examination, Thomas Repas, DO, turned to the internet. Within 20 minutes, a simple search revealed an extensive list of reliable, published articles on the rare disease.

“The internet has really revolutionized medical care. It wasn’t too long ago when we were without these opportunities,” Repas, a clinical endocrinologist in Rapid City, S.D., told HemOnc Today.

A November 2008 survey by Epocrates, a leading provider of clinical information and decision support tools for health care professionals, revealed that physicians are accessing online clinical resources more than ever. Seventy percent of the 501 physicians surveyed reported going online for clinical information at least once a day, and 20% of those reported using web-based resources five or more times a day.

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“It has totally enhanced the way we practice. Most physicians I know are wedded to it,” said Carl Pepine, MD, professor of medicine in the division of cardiovascular medicine, University of Florida, Gainesville. He said he searches the internet for information every hour, every day.

Many physicians have had experiences like Repas’ in which the internet has helped — and sometimes harmed — practice. Several shared their experiences and opinions with HemOnc Today.

The advantages of the internet as a source of health information are extensive: access to a massive volume of information, ease of updating information, more informed patients and better health outcomes, all of which can strengthen the physician-patient relationship.

According to the Epocrates survey results, the majority of respondents validated that online resources improve patient safety, are timely and economical. Nearly 90% agreed that accessing clinical information online improves patient satisfaction and communication, specifically increasing medication compliance, decreasing pharmacy call-backs, making patients appear more at ease and disclosing information that physicians would not have known otherwise.

J. Leonard Lichtenfeld, MD
J. Leonard Lichtenfeld, MD, writes a blog called Dr. Len's Cancer Blog for the American Cancer Society.

Photo by Andre Becker

“People have more access to health information and therefore have more questions and make more judgments about the quality and impact of that information. Patients have become extremely proactive in determining what they think is the right treatment for them, whether they’ll receive it and who is going to provide it,” said J. Leonard Lichtenfeld, MD, who maintains Dr. Len’s Cancer Blog on the American Cancer Society website.

“This has really changed the dynamic of the traditional doctor-patient relationship. Now, the patient can assume a higher level of participation. For the most part, this is a welcome dynamic,” said Lichtenfeld, also deputy chief medical officer for the national office of the ACS.

“The former paternalistic approach we used in medicine has given way to make the patient an informed partner. It hasn’t completely leveled the playing field because I don’t think most patients can ever get to the point in which they are as experienced as a physician,” he said.

The survey revealed that the majority of physicians have made online technologies part of the consultation to check drug dosing, adverse events, interactions and treatment guidelines during patient visits. Nearly 50% of physicians reported that they most frequently use the internet during patient consultations, rather than between patient visits or after hours.

Exploding medical blogosphere

Another way that physicians look to the internet for information is by reading blogs written by their colleagues.

Kevin Pho, MD, the web savvy author of his namesake blog, KevinMD.com, writes between five and 20 blog entries per day and keeps up-to-date with nearly 500 other blogs and websites.

Kevin Pho, MD
Kevin Pho

“Blogging is certainly a commitment,” said Pho, who gives quick takes and opinions on anything related to medicine and health care. Since starting KevinMD in 2004, Pho has accumulated a daily readership of about 10,000 and 18,000 RSS feed subscribers.

“It keeps me up-to-date in terms of medical studies and relevant issues; if a patient comes to a visit asking about something they just heard on the news that day, chances are I already know about it,” said Pho, a primary care internist in Nashua, N.H.

As a health care professional, Pho writes for colleagues and patients. “One of my main goals is to pull the curtain back on health care because a lot of people don’t really know what is going on in the doctor’s office and hospital,” he said.

The medical blogosphere has exploded and Pho’s blog is just one of many. The first blog — shortened from the term “web log” — appeared on the internet in 1997. Technorati, an internet search engine for blogs, indexed 133 million blog records between 2002 and May 2008.

William Wood, MD
William Wood

The HemOncToday.com blog launched in February 2008. Its primary bloggers, Noelle LoConte, MD, and William Wood, MD, have written blogs on a variety of hematology- and oncology-related issues, from blowing the whistle on high cancer drug prices and neuroendocrine tumors to off-label use of anticancer medications and the psychology of cancer health communication.

“My motivation for blogging was the opportunity to stay current and fresh on topics that go beyond what I do on a day-to-day basis — learning about and commenting on new developments, health policy and other issues out there in the wider world of medicine,” said Wood, a second-year hematology and oncology fellow at the University of North Carolina at Chapel Hill and a member of the HemOnc Today Editorial Board. “To the extent that people comment back on blogs that I write, it’s fun to see what people have to say; I’ve certainly seen some pretty lively discussions on blogs.”

Repas, a blogger for EndocrineToday.com, a sister publication of HemOnc Today, said “it’s amazing how blogging has taken off. Ten years ago, I never would have expected to be blogging.”

In a survey published in the Journal of Medical Internet Research, Ivor Kovic, MD, and colleagues surveyed 197 medical bloggers about blogging habits and motivations. Most were experienced bloggers, with 23% blogging for four or more years and 7% for six months or less. The medical bloggers reported best practices associated with journalism, such as including links to original source material and verifying facts and data.

The survey revealed that the major motivations for physician blogging were to share practice knowledge and skills with others and to express creativity.

“I can’t possibly read every journal or newspaper out there. For me, blogs are a way of getting a quick and dirty snapshot or take on an issue. Blogs are personal and relaxed, so it’s a nonthreatening way to stay up to speed on happenings in health care,” said LoConte, assistant professor at the University of Wisconsin School of Medicine.

On the flip side, physicians can access patient blogs to improve care. Wood recounted reading a patient’s blog.

“I learned a lot of information that I may not have learned during the course of a regular visit. I also had the ability to keep track of things better over time because I received an update whenever the blog was updated, which is certainly more frequent than clinic visits,” Wood said.

Most blogs allow readers to leave comments to generate conversation and encourage collaboration, which has created new social forums for physicians.

Fast Facts

“I’ve been in contact with physicians from around the world thanks to my blog,” Repas said. “These are people that I — in South Dakota — would never have been in contact with had I not been a medical blogger.”

If Pho has a specific question and wants the opinion of a panel of doctors, he will post an entry on his blog. “Within hours, I will have responses from a variety of physicians. Getting that instant feedback and response is very powerful,” he said.

Barriers to internet health care

“The internet has made access to medical information essentially at the patients’ fingertips. The vast majority of my patients are highly educated about their disease, testing, drugs, procedures and treatments.”

However, widespread access opens up the gate to misleading and misinterpreted information. “The internet is a Wild West. Anyone with an opinion about anything can post it,” Wood said.

Elizabeth Murray, PhD, and colleagues conducted a survey that evaluated the impact of internet health care information on the physician-patient relationship. The researchers concluded that misleading information may compromise health behaviors and outcomes or result in inappropriate requests for clinical interventions.

Additionally, “physicians may accede to inappropriate requests, either because refusal is time-consuming or because they fear refusal would weaken the physician-patient relationship. Responding to inappropriate patient requests may be particularly difficult in managed care, where patients may believe that physician refusals may be motivated by the need to control costs,” the researchers wrote in the Journal of Medical Internet Research.

Thomas Repas, DO
Thomas Repas

Most physicians that HemOnc Today interviewed said patients commonly enter the examination room with stacks of internet printouts. Internet search engines have made everyone into an “armchair expert,” according to Repas. As a consultant, he is lucky to have the time to address the information patients bring in but acknowledged that many health care professionals do not have that time.

“When patients are misinformed, I take it as a chance to educate them about evidence-based medicine and science and how we make decisions,” Repas said. This includes suggesting websites that are hematology- and oncology-approved, such as the ACS and American Society of Hematology.

Other suggestions to improve access to quality health information include seals of approval for valid websites, codes of conduct for development and content, filters, rating scales for users and public education in evaluating the quality of online information.

This often elevates the discussion in the examination room and can change the work flow and required strategies for time management.

However, when writing her blog, LoConte keeps in mind that her patients can read anything she posts.

“I get crazy comments from people who think that I push toxic poisons with my blog posts. But that’s typical for being an oncologist; some people think you can cure cancer with herbs and homeopathic remedies and others don’t. People take choosing their oncologist very seriously, as they should,” said LoConte, who also maintains a Twitter website.

Another barrier cited by physicians is a digital divide, a barrier that limits the widespread adoption of the internet as a source of health information. Patients in a higher income bracket tend to demonstrate greater access and usage compared with patients with a lower income. Novice users may lack the technical skills, experience and social connections that could help them search for and use health information on the web.

“As part of a younger generation of physicians, I’m more comfortable with the whole concept of not having to use the phone for everything,” LoConte said.

Where to Read Physician Blogs and Take Advantage of Online Resources for Health Care Professionals

“There is a learning curve with all technologies,” Wood said. “I think there are some people who are less familiar with using these things, but I haven’t seen it having a real impact on day-to-day practice. People who own personal computers and rapid internet connections are going to be able to get information a little more quickly and completely than those who don’t.”

Although Repas clearly embraces the internet, he said that he still likes the print copy of journals. “Maybe I’m old fashioned, but there is something about the smell of paper and being able to page through a book or journal,” Repas said.

Physicians HemOnc Today interviewed also cited concerns about accountability, reimbursement and privacy.

“The main hurdle for health care professionals is a strong desire for privacy,” LoConte said. “I know that most patients ‘Google’ a physician before making an appointment. I’ve had patients who I just met for the first time ask me how my two girls and husband are doing because of what they have read on the internet about me.”

Some medical bloggers blog about specific cases and disclose some details about patient encounters. “I think that every doctor who blogs is certainly aware of patient privacy issues and takes great pains in terms of taking away any identifying information. As medical blogging becomes more mainstream and more expected, I think some standards need to be set up and this issue will fade over time,” Pho said.

Future of online medical resources

“As social media and social networking gets more advanced, I definitely want to be at the forefront because there is tremendous potential in helping my patients and collaboration with other physicians,” Pho said.

Web 2.0 concepts and web culture communities are changing the development and functionality of the internet. From Facebook and MySpace to Twitter and Flickr, web culture communities create new opportunities in health care.

“Clinicians can learn a lot from social networking sites, like what patients are concerned about, what they’re interested in — the kinds of things that people may or may not find easy to bring up in the setting of a doctor’s visit,” Wood said.

Also, health care professionals have teamed up with YouTube, a video-sharing website, to engage the medical community and public. A simple search for “cancer” on YouTube revealed a variety of serious and not-so-serious videos, such as interviews with a physician about cancer treatment options and related body changes and celebrity videos and commercials to raise awareness about cancer.

Type of Information Physicians Search for Most Online

Physician Internet Use for Searching for Clinical Information Chart

Several major organizations, such as Breastcancer.org, now offer online clinical conferences that simulate the experience of attending a live clinical conference, complete with lectures and CE/CME credit.

A recent Pew Internet and American Life Project survey asked experts to predict technology and its role in 2020. Results indicate that the majority think mobile devices will be the primary connection tool to the internet for most people in the world by 2020.

Pepine said that as his practice shifts to an outpatient website, the group may close down its fax and phone number and place more emphasis on the internet and mobile devices.

Electronic prescribing practices

Electronic prescribing is also infiltrating the medical community. In 2009, the Centers for Medicare & Medicaid Services will pay a bonus to physicians for successful e-prescribing. The goal of the bonus program is to streamline the prescription process and minimize errors. An Institute of Medicine report revealed that 1.5 million Americans are injured every year by drug errors. In 2009 and 2010, Medicare will give physicians an additional 2% bonus on top of their fee for e-prescribing. In 2011 and 2012, the bonus will drop to 1% and in 2013 will decrease to 0.5%.

Policies are in the works to improve health care practices that take place on the internet. Legislators introduced a bill in the House of Representatives in June 2008 that would stop rogue pharmacies from operating on the internet while allowing consumers to fill legitimate prescriptions online.

“I hope the internet can continue to be a mechanism by which we alleviate some health disparities, particularly among disadvantaged people, and can bring people to the same level playing field as far as knowledge about disease, treatment and optimal places to be treated. I hope it can provide a forum for patients and caregivers to really feel united and together,” LoConte said. – by Katie Kalvaitis

POINT/COUNTER
Do you use e-mail to communicate with patients?

For more information:

  • J Med Internet Res. 2003;5:E17.
  • J Med Internet Res. 2008;10:E28.