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During the past decade, the Internet has evolved rapidly into a mainstream communication and information resource. One of the most important areas affected is access to information in the health care field. The Internet has not only increased access to medical literature, it has also opened new communication channels (for example, patient–physician e-mail) and on-line educational opportunities and made national and international treatment guidelines and clinical trial information more available. This new, worldwide availability of resources extends to the general public and to those who suffer from mental illness. Patients may now have more questions and inquiries about their care because they have garnered information from the Internet. This information may help them understand their condition and treatment options. Conversely, it may require psychiatrists to spend more time sifting through it to compare treatments and deal with possible misinformation. This paper examines the impact that the Internet is having and will have on the practice of psychiatry. It highlights the major Internet resources applicable to the practice of psychiatry, provides background on those resources, and relates them to clinical practice where possible. PublicationsThe peer-reviewed articles of our numerous journals and publications are a major reservoir of medical knowledge. Given the rapid changes in medicine and the extent of the medical literature, physicians have relied for the past 30 years on the resources of the US National Library of Medicine (NLM) journal archives as an access point to the biomedical literature. This database, Medline, contains over 12 million citations from more than 4600 biomedical journals and dates back to the mid 1960s. The NLM has traditionally been an important and central resource for the medical community; once known as Index Medicus, it was almost exclusively used by medical librarians, scientists, and health care professionals. In 1997, the NLM opened up free access to Medline through the PubMed (www.pubmed.gov) search system. It has now been discovered by the general public, for whom it has also become a valuable resource. Free access for everyone has altered the patient–physician relationship regarding access to scientific information. Information that once was for all practical purposes only available to the medical community is now being accessed widely, according to Lacroix and Mehnert (1). Their current data indicate that the number of Medline searches has grown from 7 million yearly in 1997 to more than 1 million daily in 2002. These data show a fiftyfold increase in use and demonstrate that a much wider audience in now accessing the scientific literature as a source of information. In 1998, the NLM introduced Medlineplus (www.nlm.nih.gov/Medlineplus), which provides full-text health information written for the consumer by the National Institutes of Health (NIH), by government agencies, and by other trusted groups. What are people looking for? According to the results of a Medlineplus survey of first-time and repeat visitors, 61% to 66% were looking for information on a specific condition, 33% to 40% were looking for information on medicines or prescriptions, 17% to 19% were looking for general health information, 13% to 18% were looking for breaking health news, 12% to 14% were looking for information on clinical trials, and 12% to 14% were looking for information on alternative treatments (2). In addition, 46% of the users were conducting further research on a condition, 30% had discussed the disease or treatment with a friend or family member, and 19% had discussed a disease or treatment with a doctor. Potts and Wyatt surveyed 800 doctors’ experiences of patients using the Internet and found that patients benefit from using it much more often than they are harmed (3). Respondents frequently identified information, advice, and social support as benefits of Internet use. They reported patients’ being misinformed as the most common problem. One-half of the physicians who participated reported longer consultations as a problem for the health service, while nearly one-half named unnecessary investigations. Bessell and others evaluated 10 comparative studies and concluded that, despite widespread consumer use to obtain health care information, evidence of any effects this may have on health outcomes is almost completely lacking (4). In a 2001 study of 4763 US self-reported Internet users, Baker found that approximately 40% of respondents reported using the Internet to look for advice or information about health or health care (5). Only one-third of those searching the Internet for health information reported that using the Internet affected a decision about their health or health care. Very few actually reported impacts on measurable health care utilization. Houston and Allison compared Internet users in good, fair, or poor health and found that sicker patients are the most likely to ask health care professionals about information found on-line (6). The psychiatric community has anecdotal information that patients are using the Internet to find information and discuss it with them, yet the literature has few studies that address the use of this information and its impact on psychiatric practice, health care economics, and illness outcomes. Without this baseline information, it is difficult to gauge the impact of this medium on the interaction between psychiatrists and their patients regarding treatment options, treatment compliance, or general understanding of the psychiatric illness. In June 2003, the Yahoo.com category “Health” listed over 27 000 health-related Web sites. This statistic highlights the huge growth in the number of health-related sites over the past decade. The most recent literature exploring the effectiveness and quality of health care sites designed for the general public indicates that this subject remains a much-debated topic (7); it is an area requiring further research. Like it or not, it appears that the general public is using the Internet to obtain health care information. Increasingly, psychiatrists will have to take on a mentorship role with their patients to provide assistance and guidance in accessing psychiatric information on the Internet. The medium is evolving from an extracurricular activity for psychiatry to a core topic that psychiatrists will be asked about and must be familiar with so that they can inform not only themselves but also their patients. Psychiatrists may find that this tool is extremely helpful in facilitating the partnership of psychiatrist, patient, and family. It may guide patients and (or) their families to appropriate resources, it may warn them of potential pitfalls, and it may manage expectations in advance. Internet use among the general public is likely to continue to grow as our children, who become Web-literate early in life, turn naturally to it to access information of all types. On-line Availability of GuidelinesThe philosophy behind the development of guidelines is based on the assumption that these documents will reduce practice variability and result in improved patient outcomes (8). However, the ongoing disparity between clinical guideline development and the reality of clinical practice has been of concern for several years, not only in psychiatry but also in medicine generally. In this regard, new technologies can bring guidelines to the point of care, and when these technologies are used as part of the clinical workflow of outpatient care, they can assist with guideline implementation. In Canada, psychiatrists can access guidelines through the Canadian Psychiatric Association Web site (www.cpa-apc.org). In the US, the National Guideline Clearinghouse (www.guideline.gov) provides guidelines for 101 mental disorders and links to the American Psychiatric Association guidelines (www.psych.org), which cover several DSM-IV diagnostic categories. Major benefits of the National Guideline Clearinghouse are that it is updated weekly, it is free, and most important, it allows psychiatrists to generate side-by-side comparisons for any combination of 2 or more guidelines. The latter feature eliminates the work of comparing and selecting key features of the various guidelines. This service not only strengthens psychiatrists’ ability to evaluate guidelines, it also allows them to incorporate novel approaches that have been reviewed by various associations worldwide and gives them access to guidelines in areas that may overlap with their own work, such as psychosomatic medicine or psychooncology. Both the medical community and the general public can access these guidelines. That being the case, psychiatrists should be aware that an extensive array of guidelines exists and that patients or their families may now at times challenge them to explain discrepancies between their treatment and evidence-based guidelines found on the Internet. Also, whereas clinical guidelines are now usually updated every 5 years, at the most, more frequent updates can be anticipated with the incorporation of research information as soon as it is released. Guideline development may become a dynamic collaborative enterprise wherein participation of many clinicians is feasible. Availability of Clinical Trial InformationThe Internet has made it easier for psychiatrists and the general public to obtain information on clinical trials being run locally, nationally, and internationally. Till and others investigated the completeness of databases for breast cancer clinical trials available on-line in Canada (9). They identified 30 sites, 8 of which met their inclusion criteria. In total, they identified 28 breast cancer trials with information available in Canada. Of the 28 trials, they found that the Physician Data Query (PDQ) Clinical Trials Database of the US National Cancer Institute (www. cancer.gov/search/clinical_trials) identified 86% (24/28). The database of the National Cancer Institute of Canada Clinical Trials Group (NCIC–CTG) (www.ctg.queensu.ca) identified 29% (8/28). CenterWatch Clinical Trials Listing Service (www.centerwatch.com) identified 4% (1/28). An extension of this study would be helpful in the field of psychiatry. For comparison purposes, the key term “Canada and depression” was entered at 3 sites to find clinical trials on depression at the time of writing (June 2003). Centerwatch (www.centerwatch.com) identified 10 studies in Canada, Medistudy (www.medistudy.com) identified 2 studies, and Clinicaltrials.gov (www.clinicaltrials.gov) identified 4 trials. The results of this simple test performed for psychiatry are consistent with the results found by Till and others (9). It appears that variability and completeness are shortcomings in this area. Nevertheless, this resource is useful and, as with the other information resources discussed above, can be accessed by the general public as readily as by a psychiatrist. Studies such as Till’s will help clinical database sites to identify shortcomings and will help to increase the robustness of this resource in the future. Such studies may also assist in developing research networks that can both disseminate clinical trial information and allow patients a greater choice in clinical recruitment, while expanding the reach of researchers. JournalsThe Internet has had a major impact on the publishing industry, which in turn has affected psychiatry. Virtually every psychiatric journal now has an on-line version. Journal publication sites all have search engines or directory trees that allow psychiatrists to find published articles. Most provide free access to the title and abstract. Pricing models for full-text articles vary: some are free, some are pay-per-article, and some include access to current and archived full-text articles with a paper subscription. One notable change in the publishing industry has had an impact on all medicine, including psychiatry: the tempo of publishing has accelerated. Many journals now “fast-track” research papers, and many publish ahead of print, as was seen in the case of publications related to the Severe Acute Respiratory Syndrome (SARS) outbreak in Canada. In 1997, the British Medical Journal (BMJ) initiated an interesting study that challenged readers to describe what future on-line articles would look like in 5 general medical journals: the Annals of Internal Medicine, the British Medical Journal, the Journal of the American Medical Association (JAMA), the Lancet, and the New England Journal of Medicine (10). Five years later, Delamonth published a follow-up article summarizing the major themes identified and scoring the realization of reader predictions on a scale of 1 to 10 (11). The 5 major themes that emerged were 1) that the article will become a living document (score 1/10), 2) that the on-line article will be a superset of the current paper article (score 3/10), 3) that links will greatly proliferate (score 5/10), 4) that articles will be available in different formats and at different levels of complexity (score 2/10), and 5) that peer review will change (score 4/10). While some of the predictions have proved better than others, overall the evolution of the publishing industry seems to have had a positive impact for medicine by expanding the interactivity and quantity of available resources. It appears that the medical community as a whole has been receptive to on-line publications. Obst compared the use of a matched set of print and on-line titles in an academic medical sciences library and found that, for the titles examined, users accessed on-line versions 10 times as often as the print version (12). Obst found that ease of access primarily determines what is read or purchased and that a tendency exists to reduce multiple access modes to a manageable few. While none of the journals examined were psychiatry-specific, they were all scientific journals published by Academic Press, Blackwell, Elsevier, Highwire, or Springer. It is reasonable to expect that many psychiatrists now access on-line versions of articles more frequently than print versions. These data suggest that publishers will increasingly emphasize their on-line journal editions: on-line versions of articles are being accessed more often, are easier to publish, and offer the most versatility in terms of linking articles and their references to other resources. Medline’s Linkout service is a good example of hyperlink use, over and above their inclusion within the articles themselves. As of June 2003, over 1000 journals have supplied links to Web-accessible resources listed in specific citations or to biological data available in PubMed and the other Entrez databases, making is easier for users to quickly access full-text articles. To enhance this synergy, journals now often link article references to Medline abstracts. Some journals, such as the American Journal of Psychiatry, Academic Psychiatry, and JAMA, have gone even further. Not only do they provide links to references, they also map articles that have been published—an approach that increases access and convenience and decreases the amount of time required for psychiatrists to master a particular area. The results of the BMJ challenge show that physicians have high expectations and that there is still room for journals to enhance their on-line services. The required level of technology already exists, and the primary factors influencing change in on-line publishing will therefore be competition, customer demand, and economics. Continuing Medical Education (CME)The Internet provides a convenient, up-to-date mechanism for psychiatrists pursuing CME from their offices or homes. It also increases the range and number of educational programs available for rural physicians. However, the use of these resources depends on several variables. Available hardware, software, and speed of Internet service will determine the speed and ease with which these courses can be accessed. The following are key issues that affect how and when psychiatrists choose to use these resources: awareness that on-line programs exist, interest and motivation to use new technology, quality and currency of the content, an acceptable educational format that is not only easy to use but also intellectually engaging, cost, registration requirements, ability to earn CME credits, and time needed to complete the program. From 1997 to 1999, Sklar surveyed on-line CME sites to collect information for several factors, such as the number of on-line CME sites available, course credit hours, on-line CME offered in different medical specialties, program costs, the number of physicians visiting on-line sites, and participation in the courses (13). In 96 sites surveyed in 1999, Sklar found that much on-line CME is organized in the same manner as are hospital meetings, specialty society meetings, and conferences sponsored by drug companies; namely, a text or text and graphics article or a slide-audio (video) is presented, sometimes followed by a postinstruction test. He found little evidence to suggest that the creators of these Web sites had incorporated theories on distance education while constructing their programs. Sklar’s finding is supported by Carrière and Harvey, who surveyed members of the Alliance for Continuing Medical Education to determine the state of distance education in North America in 2000 (14). These authors found that, while there was considerable interest in distance education, most CME providers (68% of the 200 respondents) had not developed distance education programs at the time of the survey (14). The primary reasons for not offering distance education programs included a lack of financial and human resources and concerns that distance education outcomes have not yet been well studied. Casebeer and others surveyed a random sample of 2200 US office-based physicians from all specialties to determine the use patterns for on-line CME (15). The sample size was sufficiently large for the results to represent the entire population of 324 000 physicians listed with the American Medical Association (AMA), with a margin of error between 5% and 95% confidence. Casebeer and others found that, although almost all physicians have Internet access and know how to use it, 70% reported that they had rarely or never accessed on-line CME (15). They also identified that the most common reason physicians seek information on the Internet is to solve a specific patient problem. In tandem with this finding they identified the major barrier to use as “too much information to scan,” together with “too little specific information to respond to a defined question.” To address this problem Casebeer and colleagues recommended changing the practice of transforming traditional lectures into on-line CME. They suggested designing on-line, case based programs to address physicians’ unmet educational needs. On-line CME must assist physicians to seek and collaboratively build knowledge that will improve their patient care and add to their professional competence. Further, given the changing nature of medical practice (CanMEDS; 16), physicians need to extend their competence to other areas. The greater access to educational opportunities afforded by the Internet will also assist this. With respect to psychiatrists, Casebeer and colleagues observe that specialists and those in primary care look at the Internet differently: specialists such as psychiatrists are less interested in on-line CME courses than in specialty updates—something that continuing education professionals should bear in mind. As the literature cited above indicates, physicians by the very nature of their practice seek to solve problems to help their clinical work. On-line education needs to address this. While the didactic format does provide information, it limits the opportunities for reflective learning and does not access the opportunities available from interacting with peers (17). Davis examined the effectiveness of various types of CME and showed that case discussions, role play, and hands-on practice typically change physician performance more effectively than didactic approaches (18). An alternative to the didactic on-line model is the collaborative on-line model. The on-line collaborative model uses a problem-based approach in which knowledge is constructed and negotiated with others. It extends such traditional collaborative learning as workshops and colleague discussions. More research is required to determine the on-line CME model that will yield the greatest educational outcomes and to develop methods that will be able to measure these outcomes when physicians do participate. In contrast to physicians’ warm reception of on-line publishing, it appears that the more traditional methods of CME are still favoured by the medical community. E-mail is one of the most popular Internet services; it is clearly a mainstream communication technology and is now widely used in business and by the general public. Consequently, e-mail is now part of the psychiatrist’s daily ritual and entails sifting through numerous messages, many of which are unsolicited or of little relevance. In many large institutional settings, such as hospitals, e-mail has become central to the culture of communication. Given its popularity, there is increasing pressure from the public, who want to use this technology to communicate with their physicians. Each psychiatrist will have to weigh the advantages and disadvantages of communicating with patients via e-mail. In a national survey of 60 000 US households, Baker and others found that 6% of the 4764 respondents over age 21 reported using e-mail to contact a physician or other health care professional (5). While e-mail communication with patients is not yet a mainstream activity, it is still important for psychiatrists to become familiar with its strengths and weaknesses. Patients may want e-mail contact because they perceive certain benefits from easy and almost instantaneous access to their health care professionals. They may view e-mail as a way to get a quick opinion between visits and as a way of avoiding telephone tag or speaking to an intermediary. Spielberg compared the reception of e-mail technology in medical practice with the reception of the telephone and observed that new expectations, practice standards, and potential liabilities emerge with the introduction of this new communication technology (19). It is important to set up certain guidelines regarding physician–patient communication; these should cover such issues as length of time before the patient may expect a response, content of the communication, and of extreme importance, confidentiality issues. The Canadian Medical Protective Association (see www.cmpa.org) recommends that physicians discuss the ramifications of communicating electronically with patients and obtain documented informed consent before using e-mail. The American Medical Association, through the AMA Council on Ethical and Judicial Affairs (20), has developed principles for the use of e-mail with patients. These principles emphasize that e-mail communication is meant to supplement other personal encounters rather than to establish a patient–physician relationship. It is also important that patients delineate for physicians their parameters of acceptable e-mail, so that physicians who wish to use this tool may not be seen by patients as encroaching. Kane and others’ extensive set of guidelines regarding patient–provider electronic mail address 2 interrelated aspects: effective interaction between clinicians and patients and observance of medicolegal prudence (21). These guidelines also acknowledge that different health care organizations will differ in their methods of communicating with patients and that all recommendations must be adapted to individual circumstances. Several institutions, such as the University Health Network in Toronto, have provided their health care professionals with a standard form to be signed by patients acknowledging that the use of this medium to communicate has been discussed. In terms of legal precautions, e-mails do form a permanent record that can be printed, easily forwarded to one or more people, intercepted, rerouted, or read by unintended recipients. Messages can be encrypted; however, this requires both the psychiatrist and the patient to obtain digital IDs, and even so, this does not prevent someone who has access to the patient’s or psychiatrist’s computer from reading an e-mail after it has been received. Digital IDs can be obtained from Digital ID providers such as Verisign (www.verisign.com), Thawte (www.thawte.com), Global Sign (www.globalsign.net), and other certified providers. The providers offer instructions on installing the Digital IDs; these can also be found in the Help section of the Web browser. The ability to communicate with patients via the Internet has also spawned e-therapy. This therapy uses the convenience of the Internet to provide either simultaneous communication, such as chat or e-mail messages, between patient and professional. This particular therapy format raises several issues, such as licensure, confidentiality, liability, and reimbursement. These issues also require that associations and government bodies formulate and implement guidelines. Seeman indicated that e-psychiatry is inevitable in the future and will be particularly useful for preconsultation history gathering, as well as for administering questionnaires and rating scales (22). One of the issues that has been raised is whether this type of service will be billable, since at present, according to the 1996 National Survey of Psychiatric Practice, psychiatrists spend the most hours (that is, 57.3% of their professional work hours) in direct patient care (23). Historically, this has been defined as face-to-face interactions, which have been required for fee-for-service reimbursement. A legal precedent exists in the state of California, where, since January 1997, no health care service plan can demand face-to-face contact (22). The intent is to reimburse telehealth providers to the same degree as face-to-face providers, but whether the principle can be extended to e-therapy is still a question with major implications and no answers at present. Many questions arise in this area, and as yet, we have not dealt with them. There is a great need for more research upon which to base guidelines for implementation. SummaryThe Internet has made it possible for psychiatrists to access research and clinical information more quickly and easily than ever before. It has broken down distance barriers and made it possible to collaborate with colleagues more effectively, regardless of their location. Through distance learning, it has provided rural psychiatrists with more varied training and educational options. It has given psychiatrists and the general public equal access to scientific articles, clinical trials, and guidelines. It has created the opportunity to form new relationships between psychiatrists and patients and their families, and it has opened a new communication channel that is just starting to be tapped. The general public have accepted the Internet as a mainstream health care resource, although its effectiveness on health outcomes is still being debated and investigated by the medical community. Widespread information access has both advantages and disadvantages. On the positive side, it may help treating psychiatrists to improve patients’ understanding of their condition and their treatment compliance. In some cases, it may help them to identify options for consideration. Conversely, it may make the practice of psychiatry more challenging, since available scientific data can be interpreted from different perspectives, with sometimes erroneous conclusions or misinformation accepted as scientifically correct. Most of the technological shortcomings have been or are being addressed by increasing the number of high-speed access points and by offering new and improved computers and software. The technology required to view Web pages and multimedia and to collaborate on-line has been developed and is maturing. It is well beyond the pilot stage. Policy issues regarding billing, licensure, and legal issues remain outstanding and will be clarified over time. Internet resource providers will have to find ways to reduce search times and help psychiatrists access information and CME they need to enhance clinical outcomes. While Internet resources and the hardware that psychiatrists use to access them will continue to change, it is clear that the Internet is now a mainstream medium. Its impact on psychiatry will continue to increase as more and more psychiatrists embrace this technology and integrate it into their practices. References1. Lacroix E, Mehnert R. The US National Library of Medicine in the 21st century: expanding collections, nontraditional formats, new audiences. Health Info Libr J 2002;19:126–32. 2. Medline plus Visitor Profile Survey, February 2001. www.nlm.nih.gov/Medlineplus/survey/lookm.html. 3. Potts HW, Wyatt JC. Survey of doctors’ experience of patients using the Internet. J Med Internet Res 2002;4(1):E4. 4. Besell TL, McDonald S, Silagy CA, Anderson JN, Hiller JE, Sansom LM. Do Internet interventions for consumers cause more harm than good? A systematic review. Health Expect 2002;5(1):28–37. 5. Baker L, Wagner TH, Singer S, Bundorf MK. Use of the Internet and e-mail for healthcare information: results from a national survey. JAMA 2003;289:2400–6. 6. Houston TK, Allison JJ. Users of the Internet health information: differences by health status. J Med Internet Res 2002;4(2):E7. 7. Lampe K, Doupi P, Van Den Hoven MJ. Internet health resources: from quality to trust. Methods Inf Med 2003;42:134–42. 8. Sacerio MM, Zielstorff RD, Paterno M, Teich JM, Bates DW, Kuperman GJ. Automating complex guidelines for chronic disease: lessons learned. J Am Med Inform Assoc 2003;10:154–65. 9. Till JE, Phillips RA, Jadad AR. Finding Canadian cancer clinical trials on the Internet: an exploratory evaluation of on-line resources. CMAJ 2003:168:1127–9. 10. Bero L. The electronic future: what might an on-line scientific paper look like in five years’ time? BMJ 1997;315:1692–6. 11. Delamonthe T. Is that it? How on-line articles have changed over the past five years. BMJ 2002;325:1475–8. 12. Obst O. Patterns and costs of printed and on-line journal usage. Health Info Libr J 2003:20:22–32. 13. Sklar B. The current status of on-line continuing medical education- a master’s thesis in medical information science. Available at netcantina.com/mastersthesis/. Accessed February 3, 2003. 14. Carrière MF, Harvey D. Current state of distance continuing medical education in North America. J Contin Educ Health Prof 2001;21:150–7. 15. Casebeer L, Bennett N, Kristofco R, Carillo A, Centor R. Physician Internet medical information seeking and on-line continuing education use patterns. J Contin Educ Health Prof 2002;22:33–42. 16. Martin L, Saperson K, Maddigan B. Residency training: challenges and opportunities in preparing trainees for the 21st centure. Can J Psychiatry 2003,48:225–31. 17. Wiecha J, Barrie N. Collaborative on-line learning: a new approach to distance CME. Acad Med 2002;77:928–9. 18. Davis D, O’Brien MAT, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA 1999;282:867–74. 19. Spielberg AR. On call and on-line: sociohistorical, legal and ethical implications of e-mail for patient–physician relationship. JAMA 1998;280;1353–9. 20. Bovi AM, and the Council on Ethical and Judicial Affairs of the American Medical Association. Ethical guidelines for use of electronic mail between patients and physicians. Am J Bioth 2003; 3:(3). Available from www.bioethics.net/journal/infocus.php?vol=3&issue=3&articleID=120 21. Kane B, Sands DZ. For the AMIA Internet Working Group. Task force on guidelines for the use of clinic–patient electronic mail. J Am Med Inform Assoc 1998;5:104–11. 22. Seeman MV, Seeman B. E-psychiatry: the patient–psychiatrist relationship in the electronic age. CMAJ 1999;161:1147–9. 23. Zarin DA, Pincus HA, Peterson BD, West JC, Suarez AP, Marcus SC, and others. Characterizing psychiatry with findings from the 1996 National Survey of Psychiatric Practice. Am J Psychiatry 1998;155:397–404. Author(s)Manuscript received and accepted September 2003. 1. Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario. Address for correspondence: Dr R Styra, Department of Psychiatry, University Health Network, 200 Elizabeth Street, Suite 8EN-235, Toronto ON M5G 2C4 e-mail: rima.styra@uhn.on.ca
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