Vast databases of medical information that used to be accessible only in libraries now can be reached over the Internet.
There's been much discussion on the impact of patients gaining easy access to medical literature. But the same technology also allows physicians to access data more rapidly than ever, potentially improving the quality and efficiency of care.
The prime example is Medline, the premier database of references and abstracts maintained by the National Library of Medicine in Bethesda, Md. As many as 50,000 physicians have Medline accounts, compared with a handful a few years ago. In 1995, 7.3 million searches were done on Medline, slightly more than half of them for patient care.
That doesn't include tens of thousands of other physicians who use Medline by way of CD-ROM or online services such as Physicians' Online, America Online or PaperChase.
Kaiser Permanente's Southern California division is putting Medline at the fingertips of 30,000 employees, including desktop access for all physicians. Before, physicians had to request a Medline search from a Kaiser librarian. "We're open 8 to 5 and patients are sick 24 hours a day," said Mary White, director of library and media services at Kaiser's Bell Flower, Calif., location.
Access grew with the release of an Internet version of the Medline software, Grateful Med. Starting last week, anyone with a World Wide Web browser and a credit card can do an instant Medline search. The new software also is supposed to be quicker and easier to use, offering search assistance such as a thesaurus to lead users to correct medical terms.
Several studies have suggested Medline can help physicians make better decisions, but it is not always useful for clinical care.
There is so much data-Medline has 7.5 million citations from 4,000 journals-that assimilating it all to arrive at a diagnosis and treatment options can take hours or days.
"If you're dealing with a subject you know well, Medline will help you. If you're dealing with a subject you're green on, Medline might do more harm than good," said Kenneth Melmon, M.D., a professor and associate dean for postgraduate medical education at the Stanford (Calif.) University School of Medicine.
He said large software companies are developing tools for the giant consumer market, rather than for physicians.
Stanford is among several academic institutions where researchers are trying to adapt medical databases for teaching and clinical use. The Stanford Health Information Network for Education, or SHINE, links Medline, the Scientific American Medicine reference system, a drug database from Englewood, Colo.-based Micromedex Corp., and excerpts from 150 Kaiser Permanente videos.
SHINE allows users to pose a series of questions to arrive at rapid diagnosis and treatment decisions.
Melmon said the system helps eliminate the need for second visits, which physicians often schedule to give them time to do research. The network is in use by 30 to 50 physicians at Veterans Affairs Medical Center in Palo Alto, Calif., and two Stanford clinics.
Stanford would like to link the data to electronic medical records. Another goal is to market it to other providers, but Melmon said Scientific American Medicine will not allow it.
Indeed, copyright issues and subscription fees have become barriers to integrating online information in clinical decisionmaking, even as technical hurdles are overcome, said James Cimino, M.D., an associate professor of medicine and medical informatics at Columbia University.
Cimino said he would like to give all physicians at the Columbia-Presbyterian Medical Center in New York access to an online medical textbook, but publishers are reluctant to allow their databases to be integrated into providers' systems.
Another problem is outdated hardware. Cimino recently developed a system called PolyMed, which helps physicians interpret data in electronic medical records, but only a few surgeons can use it. "Part of the problem is that our institution doesn't have machines capable of running Windows," he said.
Earlier, Cimino developed the Medline Button to link medical literature and clinical data.
Physicians can access Medline from a medical library or a nursing station, Cimino said, but it's tedious, and clinical data cannot be viewed simultaneously.
Still, Medline access is becoming universal. The NLM has signed agreements with seven medical associations, including the American College of Physicians, to allow their members unlimited Medline access for $200 a year.
The NLM also is signing fixed-fee agreements, such as the one with Kaiser, to offer Medline access at a yearly rate of $2,000 to $100,000, depending on the institution.
Some providers, such as Mayo Clinic, access Medline through companies that offer their own search engines.
A 1993 survey published in the Journal of the American Medical Association showed that physicians who use Medline believe that ready access to medical literature can improve outcomes.
However, Karen Ginter, director of Medline and other NLB databases, said providers and health plans are not requesting proof that Medline improves the quality or efficiency of care.
Rather, it's assumed it does.
Internet Grateful Med is at http: www.nlm.nih.gov. A demonstration of the Medline Button is at http: www.cpmc.columbia.edu/cisdmo.