ONLINE HEALTH INFORMATIONPatient and Physician Utilization of the

Internet as a Medical ResourceJason MitchellApril 19, 2012

ONLINE HEALTH INFORMATIONPatient and Physician Utilization of the

Internet as a Medical ResourceJason Mitchell, PGY-3

April 19, 2012

PATIENT DEMOGRAPHICS

78% of American adults use the internet

59% of all adults look for OHI

80% of internet users search online for health information 94% of internet users check email 87% of those going online use a search engine

Pew American Internet and Life Project 2010

PATIENT DEMOGRAPHICS

• More likely to search for OHI

• Ages 18-49

• Female

• Caucasian

• Higher education

• Higher income

PATIENT DEMOGRAPHICS

40-50% of patients discuss OHI with their doctors

11% used the internet instead of doctors More convenient Less expensive Physician not open to discussion Mistrust Not enough time with physician

Diaz J. J Gen Intern Med 2002

PATIENT DEMOGRAPHICS

A) Sources where patients would prefer to obtain health information

B) Sources where patients actually went to for health information

Hesse B. Arch Intern Med. 2005

ED PATIENT DEMOGRAPHICS

37%

Pourmand A. West J Emerg Med. 2011

ED PATIENT DEMOGRAPHICS

15%

Pourmand A. West J Emerg Med. 2011

PATIENT SEARCH QUERIES

• Statistics Canada, 2005

• N = 30, 466

• 60% of internet users search for OHI

PHYSICIAN DEMOGRAPHICS

86-89% of physicians use the internet for OHI

PHYSICIAN DEMOGRAPHICS

86-89% of physicians use the internet for OHI

PHYSICIAN SEARCH QUERIES

Specific Drug Information

77%

General Condition Information

75%

Drug Safety Information 66%

Information For Patients 61%

Information to Aid Diagnosis

53%Parekh N. 2009

PHYSICIAN SEARCH QUERIES

Specific Drug Information

77%

General Condition Information

75%

Drug Safety Information 66%

Information For Patients 61%

Information to Aid Diagnosis

53%Parekh N. 2009

OHI AS A PHYSICIAN AID

2006 Study

NEJM Cases

3-5 search terms Entered into Google

Diagnostic Accuracy 58% (15 of 26 cases)

Tang H. BMJ. 2006

OHI AS A PHYSICIAN AID

2011 Study

EM Residents

N = 33, PGY 1-3

Pre-test and Google Post-Test

OHI AS A PHYSICIAN AID

Pre-Test GoogleTest

Krause R. West J Emerg Med. 2011.

SEARCH STRATEGIES

How do patients search for online health information?

Eysenbach G. BMJ. 2002.

SEARCH RESULTS

2009 Study

Titles of all MEDLINEplus Health Encyclopedia, NHS Direct Online, and NORD articles entered into Google

Index of top 10 websites offered

Wikipedia was significantly in the top 10 74.5% of all search terms Medscape 44.4% Mayo Clinic 31.6% eMedicine 22.7% Merck 9.3%

Laurent M. J Am Med Inform Assoc. 2009.

ED CARDINAL PRESENTATIONS

FEVER WEAKNESS

VERTIGO CONFUSION

RED AND PAINFUL EYE COMA

SEIZURES HEADACHE

DYSPNEA CHEST PAIN

SYNCOPE NAUSEA/VOMITING

ABDOMINAL PAIN GASTROINTESTINAL BLEEDING

DIARRHEA CONSTIPATION

JAUNDICE PELVIC PAIN

VAGINAL BLEEDING BACK PAIN

CYANOSIS SORE THROAT

HEMOPTYSIS

ED CARDINAL PRESENTATIONS

FEVER WEAKNESS

VERTIGO CONFUSION

RED AND PAINFUL EYE COMA

SEIZURES HEADACHE

DYSPNEA CHEST PAIN

SYNCOPE NAUSEA/VOMITING

ABDOMINAL PAIN GASTROINTESTINAL BLEEDING

DIARRHEA CONSTIPATION

JAUNDICE PELVIC PAIN

VAGINAL BLEEDING BACK PAIN

CYANOSIS SORE THROAT

HEMOPTYSIS

QUALITY

ACCURATE

COMPLETE

UNDERSTANDABLE

Giles J. Nature. 2005.

WIKIPEDIA ON DRUGS

2008 Study Comparing Wiki entries to MDR

Wikipedia less able to provide answers (40.0% vs 82.5%, p<0.001)

Higher errors of omission (48 vs 14) Wikipedia did not provide dosing info (0% vs. 90%)

Wikipedia entries less complete (76% vs. 95.5%, p<0.001)

No factual errors, 4 in MDR

Clauson K. Ann Pharmacother. 2008.

WIKIPEDIA ON DRUGS

2011 Study Comparing Wikipedia to LexiComp

5 statins reviewed

4 of 5 articles deemed less complete than LexiComp

Missing or incomplete list Adverse Effects Contraindications Drug Interactions

Kupferberg N. J Med Libr Assoc. 2011.

WIKIPEDIA ON SURGERY

2007 Study

Identified 35 of 39 most common surgeries in Wikipedia

100% presented accurate content

37.1% contained critical omissions Significantly few articles discussed surgical risks

Devgan L. J Am Coll Surg. 2007.

WIKIPEDIA ON CANCER

2011 Study Comparing Wikipedia to PDQ

Malolan S. J Oncol Pract. 2011.

WIKIPEDIA ON MENTAL DISORDERS

2011 Study

Schizophrenia DepressionReavley N. Psychol Med. 2011.

WIKIPEDIA

Studies suggest Wikipedia Has comparable accuracy

Encyclopedias Other medical resources Expert opinion

Is incomplete

May be difficult to comprehend

OTHER SOURCES

2002 Systematic Review of MEDLINE, EMBASE, PubMed and other sources

7830 citations assessing OHI screened, 79 included

70% of included studies felt that quality is a problem

Average 35.3% of Web sites inaccurate Compared to literature, textbooks, or expert opinion 38.3% inaccurate compared to clinical practice guidelines Majority of sites written at a Grade 12 comprehension level

High heterogeneity

Eysenbach G. JAMA. 2002.

EMERGENCY MEDICINE OHI

2004 Study

Compared EM OHI to checklists created from ‘gold standards’

Evaluated MI Stroke Febrile child Influenza

Searched the 12 most frequented sites MayoClinic, MEDLINEplus, Medscape, WebMD, Yahoo!Health

Zun L. Am J Emerg Med. 2004.

EMERGENCY MEDICINE OHI

0% of websites contained complete medical information

MEDLINEplus most complete: 83%

MayoClinic.com and Medscape had greater than 50%

Majority of the websites fell between 35 and 50%

5 instances of inaccurate information Defined fever as both 37oC and 1oF above

98.6oF (37.6oC) Advised taking a cold bath if stroke symptoms

occurred

EMERGENCY MEDICINE OHI

Revised 2011

MSN Health and Yahoo!Health scored the highest Higher than MayoClinic, WebMD, NIH.gov

Majority of websites > 50%

No evaluated sites inaccurate

Median reading level Grade 9

Zun L. West J Emerg Med. 2011.

IS OHI HARMFUL?

Limited evidence to suggest harmful

Potential for: Patients believing a condition is treatable

when it is not

Patients following misleading advice

Patients making self-diagnoses that are incorrect

Initiating medical treatment that may be hazardous

IS OHI HARMFUL?

2002 Systematic Review

1512 Articles screened, 186 reviewed

3 identified cases 2 cases of emotional distress

1 case of physical harm

2% patients report knowing someone harmed by OHI

Crocco AG. JAMA. 2002.

JUDGMENT OF CREDIBILITY

Most patients believe online health information is trustworthy 72% believe all or most information

Confusion = Credibility?

2004 Study: Up to 60% unable to find answers Majority of respondents satisfied with the

answers they found

60% rated online information equal to or better than their doctors

Zeng Q. Int J Med Inform. 2004.

THE PHYSICIAN ENCOUNTER

50% bring up OHI in the context of the physician encounter

Most only want the physician’s opinion As opposed to requesting specific tests/treatments

Majority of patients felt OHI in the medical encounter had beneficial impact on their care

Trust remains high

THE PHYSICIAN ENCOUNTER

Patterns of trust for sources of health information 2002-2008

Hesse BW. NEJM. 2010.

THE PHYSICIAN ENCOUNTER

Negative impact on the patient-physician relationship

4% report negative interactions with the physician

Physician dismissive, poorly communicative, threatened

12% search for second opinion Murray E. Arch Intern Med. 2003.

CONCLUSION

The internet as a medical resource is commonplace

Quality of OHI mixed with room for misinterpretation

Patients seek collaboration with physicians

WHAT CAN WE DO?

Don’t dismiss the web-savvy patient

Emphasize interpretation of OHI within the context of the physician encounter

Identify and offer credible websites Peer-reviewed, written by experts, medically

sponsored WebMD, Medscape, MEDLINEplus,

HealthCanada

Contribute to the wealth of OHI

QUESTIONS?