Outline

Objectives
How do I use it?
How do my colleagues use it?
Other business uses
How I do not use it?
Search Engines, Meta-sites and Medline

AltaVista
Metasites
Medline
Focused Web Sites

Judging Quality
Communities
Bookmarks that travel with you
Getting Started

• Understand the role the Internet can play in your practice
• Understand the difference between, search engine sites, meta-indices, Medline search engines and focused web sites
• Understand which situation is best served by which tool
• Become familiar with several techniques for efficient web searching
• Judging the quality of what you find.
• Understand the "Communities" on the web.
• How to get your favorite bookmarks to follow you wherever you go.
• Know what is required to make this useful in your office.

• Looking up information on signs and symptoms of a diseases of which I’ve never heard - "Gianotti-Crosti"
• Remembering a diagnosis based on a lesion that I recognize: "Herald patch"
• Looking up information on a newly released drug that all my patients suddenly want "Xenical"
• Finding an article in the Star Tribune that my patient recalls reading.
• Finding patient information handouts when ours is not available or out of date "Mononucleosis." "Gynecomastia in adolescence"
• Find "Information for Patients" when I give them a sample from the cabinet.
• Get labs and reports from the hospital on that patient who shows up for follow-up after discharge (and whom you did not see in the hospital).
• Read clinical updates that are mailed to me (NEJM Index, InteliHealth Online)
• Browse Medline for the latest articles in my field of interest.

• Watch the regional radar summaries
• Check their portfolio value
• Read the CNN Headlines
• Choose an outboard motor for his boat

• Using e-mail to stay in touch with colleagues
• Generate maps and directions for travel
• Look up phone numbers

• CME
• Videoconferencing
• Searching a commercial on-line medical library of texts.

• Search Engine Sites indiscriminately index the Internet. They are not exhaustive and they can be random. Examples AltaVista and Google.
• Meta-sites use editors to gather pointers to other web sites and group them according to content. They may provide their own internal search engine that searches only the sites to which they have pointers. Examples Medical Matrix and Yahoo.
• Medline search engines provide access to peer-reviewed medical literature. Carefully indexed but generally less current than the Web. Examples: PubMed and Internet Grateful Med.
• Focused web sites are dedicated to a particular disease, drug or specialty. Can have information for both patient and provider. Examples: OncoLink, Xenical and the AAFP.

• Excellent search engine that randomly indexes pages on the web. Though many will say that search engines give unsatisfactory results, I maintain that a well tuned search will give you excellent results in short order - faster than looking it up in a text in your library
• To use a search engine you must understand that results are arranged according to the frequency of times the target term appears in the document. The more frequently a term appears on a page, the closer that page moves up to the beginning of your search results.
• If you use multiple terms, the first screen of results will contain links to documents that have your search terms appearing in it the most frequently. Be aware however that not all your terms have to appear in the results. That rare medical term, though it may be the most important to you, might not appear among your first few results.
• To get best results be sure to use terms that are quite specific to the issue at hand and only those terms. Do not use free text entry. For example, if you use the expression in AltaVista: What are the contraindications of using Celexa? you will get lots of results and few of them will be useful. If you say Celexa contraindications you may get documents that speak of contraindications but have nothing to do with Celexa. However if you use just Celexa, you will get documents that speak only of Celexa and should be able to find a link of use to you within the first few search results.
• Advanced search provides even greater tuning. Advanced search allows for Boolian Operators. Using boolian operators you can specify that your terms must appear in the document. For example: Celexa AND contraindications will give me documents that have both those terms but the first few documents may speak more of contraindications than Celexa. With Advenced search you can specify the term(s) to be used to sort the results. So for example Celexa AND contraindications sorted on Celexa will give us documents in which both terms appear and the term Celexa will appear frequently in the first documents.
• You can also specify the domain of the search results. For example Celexa AND contraindications AND domain:gov sorted on Celexa will give us the same results as in the previous example but only government sites such as the FDA or the NIH will be included.
• Finally putting double quotes around a phrase will retrieve only the documents in which the terms appear in exactly that sequence. For example elevated scapula will give over 95,000 results while "elevated scapula" gives only six and one of them was Sprengel’s deformity. Exactly what I was looking for.

• Useful when you are browsing for information. Web resources are arranged according to their focus and you are much more likely to find items of interest by just browsing. You may find other sites that you may wish to bookmark so that you have them when you need them. Examples could be patient information sites, a good dermatology site with images or a site listing CME opportunities arranged by topic, date and/or location. Two classic starting points are Medical Matrix or Yahoo.

• Search the peer reviewed medical literature. There are many conduits for searching Medline and just like with Internet search engines it is good to become familiar with one of them and stick with it. Two examples of these conduits are PubMed and Internet Grateful Med.
• "Saved searches" can be run periodically so that you can familiarize yourself with recently published articles in areas of interest to you. Internet Grateful Med gives detailed instructions to help you build your own searches as a URL that you can merely click in your browser. Vary valuable but not for the faint of heart.

• If they are specialty oriented or can serve as your starting point when looking for specific information. Again examples are OncoLink, Xenical, AAFP or the On-Line Mendellian Inheritance in Man database (OMIM).

• Just like with a medical journal it is important to look at the source and the sources funding. Examples:

.com	commercial site
.edu	educational institution
.edu/~paul	Paul’s web pages at the educational institution
.org	Non-profit organization
.net	A regional internet provider
.mil	Military institution
.gov	Government site
.us	United States
.jp	Japan
.uk	United Kingdom

• Lets Use Google to find information about Internet domains:

Well-run discussion lists are quite valuable. If you have a specific interest, you can sign on to a discussion list and participate in the discussion or else just listen and learn. Two lists that have been running for over 5 years are Family-L which deals with Academic family medicine issues and OBGyn-L which deals with items of interest to the gynecologist / obstetrician. Both are able to maintain their focus and consequently are of high value to their participants and to the folks who just sign on to listen. Discussion lists are especially useful if you are interested in a topic that is not supported in your community. Via a discussion list you can link up with individuals around the world who share your interest. You can debate issues and best of all you both do not have to be on-line at the same time. You can read and reply to messages at your leisure. Your specialty society may have resources such as this available to you. You may also find lists of interest by word of mouth at society meetings, by searching for health related lists at http://www.lizst.com or one of the other physician oriented web sites.

My job requires that I work from multiple locations from multiple computers. Bringing my own personal bookmarks from one site to another is impossible. Often times I depend on AltaVista to find the website if my memory fails me (example On-Line Mendelian Inheritance in Man (OMIM). Using AltaVista and searching for OMIM brings up the website within the first 10 results.) A not very simple solution is to build your own webpage that has links to sites of interest to you but these would be very difficult to maintain for the average physician user. Http://www.myhq.com is a website that allows you to build a page of personal bookmarks that will be available to you from anywhere in the Internet. Editing and rearranging them is quite simple. The page loads fast and to date has no advertising. I use this site to store the bookmarks I am most likely to need when I am away from my machine. There are other sites which allow you to build your own bookmarks, but I have yet to find one that works better than MyHQ.

Sometimes the most significant hurdle to overcome is not one’s distaste for using a computer, but to actually have access to one in the clinical setting. If you are lucky enough to have a machine available to you that is connected to the Internet, you are the exception and not the rule. Computers have been considered to be too expensive, they take up too much space and break too easily. Largely this is still true but these issues are rapidly changing. This perspective on computers has served to perpetuate the myth of the computer-phobic physician. If we don’t have one available to us, how can we ever learn to use one?

Lets assume you wish to use the Internet in the clinical setting. The following are a few suggestions to make your journey a bit more successful and pleasant:

• The most important factor is having a computer in your work area that
1. can be continuously connected to the Internet,
2. has enough memory to allow Netscape or Explorer to stay running whether or not they are currently being used,
3. that does not have someone who has to spend > 50% of their work time on it in order to get their work done.

• If you do not have access to a computer at the office, consider getting a small laptop, with a cheap color printer. Install a phone line for it and get an account with an Internet Service Provider who will allow you to stay connected at all times. When you get to work, plug in your laptop, connect to the Internet and get your browser running then start your normal work day. I have found that the time spent in starting and concluding a successful search takes considerably less time than it takes current day computers to start up (Never mind connecting to the internet or starting the browser). Since using it is convenient, I am more likely to use it and the more I use it, the more uses I find for it.

• Essentially the computer must be:
1. Continuously connected to the Internet
2. Readily accessable from your clinical work area.
3. Ready to print out documents that you can give to your patients or place in the chart.
4. Equipped with enough memory to run your web browser and several other applications simultaneously without getting bogged down (minimum 64 Megabytes)
5. Does not have a staff person that needs to use it throughout most of the day in order to get his or her work done.

• Take the time to explore and play. Skills gained during unstructured exploration will make searching for information when under-the-gun a great deal easier and consequently you will be able to find your information much faster.

Paul Kleeberg, M.D.          O   o         Paul@Allina.Com
Allina Health System        -+---+-    Voice: 612-775-1338
1375 Willow Street           |_o_|       Family Practice &
Minneapolis, MN 55403 USA   / \|/ \   Information Services