Electronic Medical Information

1. Electronic Medical Information at your fingertips Dr. Ramesh Mehay Course Organiser, Bradford

2. Aims and Objectives • Aims • To use the internet and especially the WWW to find and evaluate information. • Objectives By the end of this section you will: • have experience in using the web to search for information • be able to select an appropriate search tool to locate different types of information • be able to evaluate internet-based information found using these search tools

3. The World Wide Web is a global system of linked documents transported through the Internet

4. list the ways you can search for information • Journals • Books • Magazines • Colleagues • Update meetings • THE INTERNET

5. what’s the problem with the net? • Information sources • Cataloguing • Subject coverage • Quality control

6. tools on the net • Websites • Search Engine • Metasearch • Health gateway • Computer databases eg MEDLINE • Discussion rooms/Chat forums (beware)

7. recognised websites Depends what you’re looking for: Clinical Information www.gpnotebook.co.uk(excellent) www.prodigy.nhs.uk www.bnf.org/bnf/(drugs) www.nice.org.uk(guidelines) www.merck.com/mrkshared/mmanual/home.jsp(MERCK MANUAL) - free EMIS Mentor Patient Information www.patient.co.uk(excellent) www.prodigy.nhs.uk Research www.jr2.ox.ac.uk(bad URL name) www.cochrane.org www.dtb.org.uk(drugs & research, password) www.clinicalevidence.com http://www.nelh.nhs.uk/(portal to all above research sites; excellent) Clinical Databases: Medline, Cinahl, Embase www.nlm.nih.gov(medline) d

8. notes of wisdom Which websites can you trust? • Don’t believe everything you read • Use information wisely • The internet is only one of many resources

9. Website Validity mnemonic www WHO (evidence: about us, contact us, URL) • URL • author's or organization's credentials. • support from a recognised support group? • site maintained by a reputable health organization (EXPERIENCE) • Be wary of (1) web sites advertising (2) selling products (3) claim to improve your health (4) bulletin boards (5) "chat" room sessions WHERE • source of the information (?quoted journals etc) • which country? (evidence: about us, contact us, URL) WHEN(evidence: about us, last updated date) • date of publication • site regularly updated? OVERALL IMPRESSIONS COUNT TOO • ask yourself whether the information or advice seems to contradict what you already know as a doctor. • cross check against other resources. • http://www.judgehealth.org.uk/

10. What the URL tells us http://www.jr2.ox.ac.uk • http:// = hypertext transfer protocol • www.jr2.ox = server name • .ac = type of organisation responsible for the site • .uk = country code what’s your conclusion about this site?

11. Search Engines • automated keyword searching tools • 'spider' or 'crawler' • generate indexes of information they find • search engine rankings • continuously trawl the networks When to use: • If you want lots of info • If you have a specific query eg “rabbit haemorrhagic disease” • To look up people or organisations eg “braindead society” Always use the advanced search option

12. Which One? Stick to one • Google www.google.co.uk If u want to try and alternative: • Altavista www.altavista.co.uk

13. Metasearch Engines • Search multiple engines • Work in the same way as a search engine • Displays less results but with more relevance When to use: • If you have a specific information need • If you want to save time • If you want to increase the range of web resources searched

14. Which One • Ixquick www.ixquick.co.uk • Ask Jeeves www.askjeeves.co.uk

15. (Subject) Gateways • These provide free access to a catalogue of health and medical Internet sites. • You can look for information under subject sections, or search the gateway using keywords. • Gateways vs Search Engines When to use • If you want GENERAL information in a specific subject area • If you want access to structured, high quality information

16. which one • OMNI = excellent www.omni.ac.uk • NHS Direct www.nhsdirect.nhs.uk • NeLH = excellent www.nelh.nhs.uk • Medix-uk • Doctors.net

17. Computer Databases • An archive of research material • MEDLINE www.nlm.nih.gov. When to Use • When you are looking for the evidence behind something

18. How to Search Generally • Define what you seek • Now think about what sorts of resource might help • Websites • search engines • gateways (NELH)

19. Smart Searching finding the needle in the haystack • search engines are not mind readers.  • Increase your chances of getting relevant results by being precise and thinking carefully about the specific words or terms you enter in the search box.  NB: Yes +music +“jon anderson”

20. Simple Search Engine Guidelines

21. Revise your search strategy until you get what you want

22. Failures • using the wrong search tool for the job • using vague terms • misspelling terms Tips: • Don’t get lost (jumping from one link on a site to the next ‘cos it looks interesting) • Keep trying and experimenting – refine your search if you fail to succeed the first time • Trust no one until you’ve found a good cause to do so

23. Practical Session 1 • You refer John Temple, a 78 year old with peripheral vascular disease to the vascular team. Letter from consultant as follows: • “I have started him on a course of cilostazil and would be grateful if you would continue this” • Prescribe or not?

24. solution • NeLH (general search) • Based on the limited available evidence, cilostazol does not appear to have any advantage over pentoxifylline in terms of safety and efficacy. Keeping safety, efficacy and presumptive cost factors into consideration, there is a minimal chance that cilostazol will replace pentoxifylline at the present time. • Clinical Evidence • Six RCTs found that cilostazol improved claudication distance at 12–24 weeks compared with placebo. However, adverse effects of cilostazol were common in the RCTs, and included headache, diarrhoea, and palpitations. One RCT found limited evidence that cilostazol increased initial and absolute claudication distance compared with pentoxifylline. The RCTs have some weakness in their methods, which may limit the applicability of the results .

25. Practical Session 2 • Mrs Joyce Finlay is a 56 year old newly diagnosed with lung carcinoma. She has recently visited the Bristol Centre for Cancer Care who have advised that she might wish to consider carctol, an anti-cancer herbal treatment. • She comes to see you to ask what you think and whether it is worthwhile. • How do you proceed?

26. Joyce Finlay • NeLH : nothing; clinical evidence: nothing • Search Engine : Google • Keywords: carctol +cancer • www.cancerhelp.org.uk • Validity: about cancerhelp> statement of editorial integrity  • Websites selling Carctol say it has been scientifically tested and refer to clinical trials.  We haven't found any claims that are supported by any real evidence.  The studies described don't seem to be clinical trials as much as surveys of people who have tried this herbal mix.  The trouble with surveys like this is that there is no way of knowing what would have happened if people hadn't taken the herbal treatment. • Having said that, there are no reports of any harm from Carctol so far. • Drink water that has been boiled • The other thing to mention is that CARCTOL costs money. A months course can cost between £45-90.

27. Practical Session 3a • Julie Fischer, a 28 year old is 24 weeks pregnant. She comes in because she is concerned about being in contact with someone with chicken pox. She cannot recall having ever had chicken pox herself. • What advise do you offer? (Can you remember?)

28. Julie Fischer • www.gpnotebook.co.uk or www.omni.ac.uk • Keywords: pregnancy chickenpox • if chickenpox in pregnancy, or a woman is varicella zoster (VZ) antibody negative and is exposed to chickenpox during pregnancy, then consult expert advice • zoster immune globulin should be given for VZ antibody negative contacts exposed at any stage of pregnancy. Note that VZ immune globulin does not prevent infection (even when given within 72 hours of exposure). However it may attenuate disease even if given up to 10 days following exposure (1). The outcome in pregnant women is not adversely affected if there is a delay in administration of VZ immune globulin for up to 10 days after the initial contact whilst the VZ antibody status is determined (1)

29. Practical Session 3b • Diane Emmet is concerned about her little boy. He was referred to the child development centre for concerns around slow development. They have finally come to a diagnosis of “Batten’s syndrome”. She would like more information and in particular the outlook for her child. • Advise

30. Diane Emmet • www.gpnotebook.co.uk • Keywords: Batten’s Clinical features include: • normal development for the first two years of life, which then begins to slow and progress to dementia • retinitis pigmentosa, visual loss and eventually blindness • fits - myoclonic jerking • ataxia • spastic weakness • athetosis Ultimately there is death in late childhood.

31. Practical Session 3c • Mary Tyler is a 34w pregnant lady who comes to see you to ask whether she would be exempt from wearing a seatbelt as she finds it uncomfortable. • She remarks “I can’t understand how anyone could ask me to wear one in the state I’m in” • What advise would you give?

32. Mary Tyler • www.gpnotebook.co.uk • Keywords: pregnancy seat belt • Pregnancy does not offer automatic exemption form the requirement to wear a seat belt. • Trauma sustained in a road traffic accident is hazardous to baby and mother. The best protection is to wear a normal seat belt with the lap strap across the thighs, to restrain the pelvis and the diagonal strap across the shoulder and chest, avoiding the abdomen.

33. Practical Session 4 • During a random case analysis you identify your GP registrar prescribes antibiotics for nearly all cases of acute otitis media. You challenge him. • He asks you about the evidence behind this. • How could you advise him during the session

34. GPR • As adult learners, the ideal is to get him to look it up for himself. However, as my registrar said to me, sometimes GPRs just want a straight answer. Bandolier at: jr2.ox.ac.uk • Knowledge library>ENT>abx in acute OM • AL Kozyrskyi, GE Hildes-Ripstein, SE Longstaffe et al. Treatment of acute otitis media with a shortened course of antibiotics. JAMA 1998 279: 1736-42. Clinical Evidence • ENT>otitis media with effusion>antibiotics • Loads of references

35. Last Slide Learn how to use the internet effectively As we've seen ... • Used carefully, the Internet can be a great source of information • Used badly, the Web can be a great time-waster To avoid spending time wandering aimlessly around the Web ... • Go to recommended Web sites in the first instance • Use search tools and keywords effectively • Evaluate the quality of the resources you find and select only reliable information The key to finding information on the Internet, or anywhere else, is to take a moment to make a plan of action.

36. Source • http://www.niams.nih.gov/hi/topics/howto/howto.htm • http://www.lincoln.ac.nz/libr/websearch/task1.htm • http://www.judgehealth.org.uk/consumer_guidelines.htm = excellent! • http://www.netskills.ac.uk/ (click on tonic) = excellent online internet training package (free registration) • http://www.vts.rdn.ac.uk/tutorial/health?sid=3343638&op=preview&manifestid=50&itemid=3476 = another excellent online internet training package • http://www.netskills.ac.uk/TonicNG/cgi/sesame?detective = another excellent training tool (free registration)