JBJS | The Emerging Impact of the Information Age on Orthopaedic Surgery* : Electronic Resources for the Orthopaedic Surgeon

The Journal of Bone & Joint Surgery, Volume 82, Issue 10

Symposium | October 01, 2000

The Emerging Impact of the Information Age on Orthopaedic Surgery* : Electronic Resources for the Orthopaedic Surgeon

Jay D. Mabrey, M.D.

American Orthopaedic Association
*Presented at the Annual Meeting of the American Orthopaedic Association, Sun Valley, Idaho, June 7, 1999.
Address for J. D. Mabrey: Department of Orthopaedics, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78284-7774. E-mail address: mabrey@uthscsa.edu.

The Journal of Bone & Joint Surgery. 2000; 82:1494-b-1494

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Introduction

One of the greatest challenges faced by orthopaedic surgeons today is the management of their most valuable resource: time. The RAND study estimated that a full-time-equivalent orthopaedist spends an average of 2200 hours per year in direct patient care¹⁰. Although critics of this study have argued that even this figure is too low⁷, Weinstein pointed out that "simply keeping up with innovations in scientific and quality-control techniques requires a commitment by most physicians to a course of lifelong education."⁷

Electronic technology will allow the surgeon more freedom to pursue educational programs without having to leave his or her practice for several days just to keep up with the latest trends in orthopaedics. As orthopaedic educators acquire experience with the multimedia format, more lectures and courses will be structured toward easy conversion to a CD-ROM or Web-based format.

The Committee on Electronic Media and Education (CEME) for the American Academy of Orthopaedic Surgeons (AAOS) is charged with facilitating that "course of lifelong education" through (1) developing high-quality home-study multimedia courseware, (2) creating electronic databases for the efficient search and retrieval of orthopaedic information, and (3) enhancing information exchange among orthopaedic surgeons. The solutions to these challenges fall into four overlapping areas of interest: electronic media, the Internet, e-mail, and telemedicine.

Electronic Media

The development of affordable CD-ROM drives for personal computers has allowed educators to offer multimedia courseware, databases, and electronic journals that often encompass hundreds of megabytes of information. The guided-learning process has best been put to use in the CD-ROM "The Athlete's Knee," which offers three case presentations that bring out many salient teaching points of sports medicine. The interactive nature of this CD-ROM guarantees that each user will experience the material in a unique manner that best fits his or her learning style. Computer disks such as the Journal of the American Academy of Orthopaedic Surgeons (JAAOS) and Instructional Course Lectures (ICLs) allow the orthopaedic surgeon to fit an entire bookshelf into his or her briefcase and take it back home or on the road. Reference CDs, such as Orthopaedic Medline and Code-X, concentrate enormous quantities of information into one spot for quick and easy access. The development of the new DVD (digital versatile disk) format will allow storage of up to eight times the amount of information currently crammed onto one CD.

Identification of the location of any specific piece of information within this extensive offering of CDs can be a daunting task for even the most computer-savvy user. A search engine is a computer program that ferrets out the requested information in a brief period of time. The AAOS recently replaced the search engine that ran on all of its CDs with one that is faster and that also allows integration of these CD-based databases with online databases accessed over the Internet.

The next step in the development of electronic media by the CEME is the integration of hard-copy media formats such as CD and DVD with additional materials accessed in real time from the Internet. This will be the core of the new AAOS CD "The Arthritic Knee," which will offer interactive case-based instruction along with direct access to arthritic knee discussion groups that are based at the AAOS Web site.

Internet

Development of the Internet has exploded within the last two years at a rate unprecedented in the realm of electronic communication. At the end of 1998, there were more than 150 million users online worldwide³, accessing 7,370,946 Web sites¹¹. Between eighty-eight and ninety-two million of these users were in the United States alone. It is predicted that there will be more than 320 million Internet users worldwide at the end of the year 2000 and more than 720 million users by the end of 2005³, with the number of users in the United States increasing to more than 207 million, or 29 percent of Internet users worldwide.

Eighty-five percent of physicians surveyed reported using the Internet¹², which was an increase in regular online activity by doctors of 42 percent in the preceding three months and an increase of 875 percent compared with the percentage in 1997. These numbers are not lost on Internet startup companies such as WebMD, which plans to give away as many as 60,000 personal computers in an attempt to entice doctors to sign on with its Web-based service that connects physicians' offices to hospitals, insurance companies, and medical information sources¹⁷.

An excellent overview of Internet resources for orthopaedic surgeons can be found in the Current Concepts Review by Golladay et al.⁵. Those authors listed several orthopaedic Web sites as well as provided an organizational overview of the Internet.

Through its Web site (www.aaos.org), the AAOS offers several online educational opportunities, including continuing medical education, case reports, orthopaedic flashcards, and special-interest examinations. There also are several online discussion groups covering such basic topics as hand surgery, hip and knee reconstruction, and sports medicine, all the way to organizational issues such as discussions of emergency-room call and insurance-company monopolies. Future projects will use what is known as the "Next Generation Internet" to carry far more information at once than the current technology allows. One such project, a cooperative effort between the AAOS and the Center for Human Simulation (www.uchsc.edu/sm/chs/) at the University of Colorado Health Sciences Center in Denver, would allow surgeons to access the Virtual Human Database in real time in order to view three-dimensional models of any organ system or muscle group that they choose. A fascinating example can be found at www. uchsc.edu/sm/chs/gallery/wrl_page/wrl.htm), which demonstrates a virtual patella that can be viewed and rotated from any angle online.

E-mail

Healtheon Corporation, an Internet company started in 1996 by Jim Clark, one of the founders of Netscape, surveyed more than 10,000 physicians and found that more than 63 percent were using e-mail daily and that 33 percent had used e-mail to communicate with patients¹². They also noted that doctor-patient communication via e-mail had increased 200 percent in the preceding year and nearly 20 percent in the preceding three months. Electronic communication between patients and their doctors did not even register as a significant behavior when physicians were surveyed in 1997¹².

E-mail has the potential to "induce cultural changes in the delivery of care even more revolutionary than any restructuring that is going on today."⁹ It facilitates communication among virtually all members of the health-care system, enabling physicians to communicate with colleagues, insurance companies, pharmacies, and hospitals and to interact with patients¹³.

In part because of the widespread adoption of e-mail in medicine, there are several caveats to consider when orthopaedic surgeons use it in a medical setting. First and foremost, "e-mail provides direct evidence of a patient-physician conversation."¹³ Any time that a patient is discussed or mentioned in e-mail, that document becomes part of the patient's medical record, and "it should be stored electronically or printed in hard copy"¹³ and treated like any other clinic note. It should be noted that the patient also has a copy of the message.

Second, if this communication is to be considered part of the legal medical record, orthopaedic surgeons must be concerned with "verifying and ensuring the authenticity of their electronic communications."¹³ One such technique is to incorporate a Digital ID into the message. Digital IDs, also known as digital certificates, bind an identity to a pair of electronic keys that can be used to encrypt and sign digital information. A Digital ID makes it possible to verify someone's claim that he or she has the right to use a given key, helping to prevent people from using phony keys to impersonate other users. Used in conjunction with encryption, Digital IDs provide a more complete security solution, ensuring the identity of all parties involved in a transaction¹⁶. The VeriSign Digital IDTM¹⁶ is now in use throughout the entire University of Texas system.

The possibility of physicians being inundated with online health requests is very real. Half of all individuals who look up health information on the Web state that they would like to communicate with their doctor by e-mail². Fortunately for orthopaedic surgeons, only 3 percent of all patients are accessing the Web for health information². According to Jeff Gruen of HealthCentered, a physician-practice strategy and consulting firm, only 5 percent of physicians recently surveyed actually use e-mail for practice purposes⁶.

The American Medical Informatics Association has established a set of guidelines for the use of e-mail in medical practice⁸. These guidelines, which are currently under review by the American Medical Association, suggest that physicians should print out all e-mail correspondence and attach it to the patient's medical record as a "progress note." Surgeons who place their e-mail addresses on the Web for the public to see should be prepared to answer the ensuing questions with great care, particularly if the requests come from out of state. Physicians who transmit e-mail messages across state lines for the purpose of rendering medical advice may unwittingly be practicing medicine without a license^13,15.

In short, it is prudent for the physician to maintain caution when responding to any e-mail from an unknown source. Feldman et al.⁴ recently reported on a series of "virtual factitious disorders," or cases in which individuals pretend to have an illness in order to attract attention and sympathy. These cases of "Munchausen by Internet"¹⁴ can erode the physician's time online as well as his or her trust in the medium.

Telemedicine

The expanded growth and speed of the World Wide Web has created as many opportunities as it has pitfalls for physicians willing to share the risk. The annual market for Web-based medical services is estimated to be as much as $250 billion⁶. Part of that growing market increasingly involves the use of telemedicine, broadly defined as the transfer of electronic medical data (that is, high-resolution images, sounds, live video, and patient records) from one location to another. For less than $50, physicians can attach a simple camera to their computer and conduct videoconferences across the Web at virtually no cost.

The AAOS, in a position statement issued in December 1999, supported the appropriate use of telemedicine to ensure access to specialists, provided that there is appropriate reimbursement for these services¹. The AAOS also recognized that the increased use of telemedicine encompasses problems not seen during the course of a conventional face-to-face encounter, such as the doctor being in one state and the patient in another. This leads to problems with state licensure, informed consent, and confidentiality.

With no consistency among insurers as to whether telemedicine services will be recognized for reimbursement and no consistency among states with respect to conducting telemedicine consultations across state boundaries, it is incumbent upon the physician to utilize extreme caution when exploring this field.

Address for J. D. Mabrey: Department of Orthopaedics, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78284-7774. E-mail address: mabrey@uthscsa.edu.

References

American Academy of Orthopaedic Surgeons: Position statement. Telemedicine, computers and the Internet. American Academy of Orthopaedic Surgeons, www.aaos.org/wordhtml/papers/position/telemed.htm, 1999.

Carrns, A.: Three words doctors dread: you've got mail. Wall Street J., p. B1, Dec. 9, 1999.

Computer Industry Almanac: Over 150 million Internet users worldwide at year-end 1998. Computer Industry Almanac, www.c-i-a.com/199904iu.htm, 1999.

Feldman, M. D.; Bibby, M.; and Crites, S. D.: `Virtual' factitious disorders and Munchausen by proxy. Western J. Med.,168: 537-539, 1998.168537 1998

Golladay, G. J.; Kirschenbaum, I. H.; Matthews, L. S.; and Biermann, J. S.: Current concepts review. Internet resources for orthopaedic surgeons. J. Bone and Joint Surg., 80-A: 1525-1532, Oct. 1998; erratum, 81-A: 144, Jan. 1999.

Gruen, J.: The physician and the Internet: observer or participant?. MD Comput.,16: 46-48, 1999.1646 1999

Heckman, J. D.; Lee, P. P.; Jackson, C. A.; Relles, D.; Weinstein, J. N.; Gebhardt, M. C.; Simon, M. A.; Callaghan, J. J.; and D'Ambrosia, R. D.: Symposium. Orthopaedic workforce in the next millennium. J. Bone and Joint Surg.,80-A: 1533-1551, Oct 1998.80-A1533 1998

Kane, B., and Sands, D. Z.: Guidelines for the clinical use of electronic mail with patients. The AMEA Internet Working Group, Task Force on Guidelines for the Use of Clinic-Patient Electronic Mail. J. Am. Med. Inform. Assn.,5: 104-111, 1998.5104 1998

Kassirer, J. P.: The next transformation in the delivery of health care. New England J. Med.,332: 52-54, 1995.33252 1995

Lee, P. P.; Jackson, C. A.; and Relles, D. A.: Demand-based assessment of workforce requirements for orthopaedic services. J. Bone and Joint Surg.,80-A: 313-326, March 1998.80-A313 1998

Netcraft: Netcraft Secure Server Survey. Netcraft, www.netcraft. com, 1999.

Nicholson, L.: Research shows 42 percent growth in physician use of Internet in last 3 months. Healtheon Corporation, www. healtheon.com/news/pr_5_06a_99.html, May 6, 1999.

Spielberg, A. R.: On call and online: sociohistorical, legal, and ethical implications of e-mail for the patient-physician relationship. J. Am. Med. Assn.,280: 1353-1359, 1998.2801353 1998

Stephenson, J.: Patient pretenders weave tangled "Web" of deceit. J. Am. Med. Assn.,280: 1297, 1998.2801297 1998

U.S. Department of Commerce: U.S. Department of Commerce Telemedicine Report to Congress. U.S. Government Printing Office, www.ntia.doc.gov/reports/telemed, 1997.

VeriSign: Digital ID introduction. VeriSign, www.verisign.com/ client/support/index.html, 1999.

Woody, T.: WebMD; getting those doctors to pay. The Industry Standard, www.thestandard.com/articles/display/0,1449,1876,00. html, Oct. 4, 1998.

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