MedReach: building an Area Health Education Center medical information outreach system for Northwest Ohio^,

Abstract

In collaboration with regional partners in northwest Ohio, the Area Health Education Center (AHEC) program at the Medical College of Ohio (MCO) at Toledo is reaching out to underserved areas, helping to provide educational opportunities to health care professionals in these communities. This paper describes the development of MedReach, a medical information outreach system that connects regional AHEC sites to MCO via the Internet. MedReach provides physicians and other health care professionals access and support to search computerized textbooks and databases for current information on medical diagnoses, treatments, and research. A unique aspect of the MedReach project is that users are able to receive personal help with information retrieval by calling or emailing MCO's outreach librarian. Periodically, the AHEC program and the Mulford Library at MCO also sponsor an educational program, titled “Medical Applications of Computers,” for regional practitioners. Current feedback on both the medical information outreach system and the educational program has been positive.

INTRODUCTION

By creating, building, and fostering regional partnerships, the Area Health Education Center (AHEC) program at the Medical College of Ohio (MCO) at Toledo has become a health care resource for clinical, continuing, community, and career education for northwest Ohio. In an ongoing effort to broaden information access, as well as education and research opportunities for regional practitioners, MCO's AHEC program has created MedReach, a medical information outreach system. MedReach provides computer connections between remote AHEC sites and MCO. AHEC sites and MCO preceptors are provided with access and support to search computerized textbooks and databases for current information on medical diagnoses, treatments, and research.

BACKGROUND

There is evidence that physicians lack timely, relevant medical information. A study of physician information needs in office practice found that only 30% of physicians' information needs were met during the patient visit [1]. Research shows that rapid access to medical information is useful and possibly reduces health care costs. An analysis of questions posed during clinical teaching indicated that 23% of clinical questions could be answered by a library, a textbook, a journal, or MEDLINE [2]. According to Marshall,

the timely use of publicly accessible, electronic databases containing bibliographic and full-text information has the potential to (1) assist in the maintenance of health professional competence, (2) decrease the isolation and lack of up-to-date knowledge experienced by health professionals practicing outside of major population centers, and (3) improve the quality of patient care by narrowing the gap between the publication of scientific findings and their application by researchers and clinicians. [3]

A study of the effect of online literature searching on length-of-stay and patient care costs found that timely patient care–related information retrieved from librarian-mediated MEDLINE searches might reduce hospital costs, charges, and lengths-of-stay [4]. Also, computerized information resources might provide improved access to medical information. Haynes et al. stated “access to the medical literature through personal computers … can greatly reduce logistical barriers to using recently published journal articles to support clinical decisions” [5].

A need for medical information outreach services also exists in rural areas. A 1990 survey of 573 physicians in the Rio Grande Valley in Texas found the predominant reason physicians cited for not doing MEDLINE searches was that there was no local access to MEDLINE [6]. A 1987 needs assessment of rural health professionals in West Virginia found that there were three major obstacles to accessing biomedical information: inadequate local resources at West Virginia hospitals, West Virginia's rural environment, and limited computer literacy among West Virginia's health professionals [7].

Several medical information networks have been instituted to increase the amount of medical information available to rural physicians. The Georgia Interactive Network for Medical Information (GaIN) offers its member individuals and institutions access to full-text textbooks and journals via MD Consult, evidence-based medicine resources via the Cochrane Library, full-text online medical journals, regularly updated literature alerts in a variety of specialty areas, access to the collective online catalog of the member institutional libraries, and reference and document delivery services [8]. The Florida Health Information Network (FHIN) provides services to the University of Florida Health Science Center (UFHSC) and to health professionals statewide [9]. Members who pay the FHIN annual fee have twenty-five hours per year of dial-in access to MEDLINE and other medical literature databases on the FHIN network and borrowing privileges at the UFHSC Library. The West Virginia CONSULT network provides computer-based information services, training, and support to West Virginia's rural health care practitioners, including online guides and databases, evaluated Websites, and MEDLINE [10]. The Synapse network offers University of Nebraska Medical Center volunteer faculty, staff, students, and Nebraska Health System related health care providers access to MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and MICROMEDEX [11]. VTMEDNET, Vermont's Health Information Network, provides University of Vermont College of Medicine and other affiliates with access to databases including MD Consult, Harrison's Online, MEDLINE, and CINAHL [12].

Most of these networks provide access to MEDLINE, and some provide access to MD Consult and CINAHL. Some of the networks provide other significant services: GaIN provides access to the Cochrane Library and regularly updated literature alerts; Synapse provides access to MICROMEDEX; CONSULT has online guides and evaluated Websites. However, none of these networks appears to provide the amount and variety of information and services that the MedReach network does.

THE AREA HEALTH EDUCATION CENTER (AHEC) MISSION

The mission of the National AHEC Program is to improve the supply and distribution of health care professionals through community and academic educational partnerships in an effort to increase access to quality health care. In collaboration with regional partners in northwest Ohio, MCO's AHEC program reaches out to underserved areas, helping to provide educational opportunities to health care professionals in these communities. A new information retrieval system, MedReach, has been developed to connect remote AHEC sites to MCO, giving them access and support to search computerized textbooks and databases for current information on medical diagnoses, treatments, and research.

THE MEDREACH SYSTEM

In the fall of 1997, the Center for Creative Instruction (CCI) at MCO assisted the AHEC program in updating their information retrieval system from a text-based system to a more user-friendly, Web-based system called MedReach. Figure 1 shows the logo that was developed. Various information resources used in medical school and practice are available to AHEC preceptors and students on AHEC clerkships, as well as other health care professionals. All users have access to a centrally located, state-of-the-art computer at each remote site (currently, there are thirteen), and AHEC preceptors can connect to the system from their offices and homes via a local Internet service provider. Much of the information is licensed, however, and access must be restricted. Sites, as well as preceptors, are assigned usernames and passwords to search restricted resources such as health sciences databases, as well as full-text databases and CD-ROMs. These resources are not available elsewhere or are only available through commercial subscription services.

Figure 1.

The MedReach logo

The MCO AHEC Web pages have been designed to make available in one location all the medical resources health care professionals may need or want.§ In addition to linking to Internet sites with medical information and resources, MedReach provides remote access to resources supported by MCO's Raymon H. Mulford Library and has the capability of running Windows applications on the Internet (e.g., full-text databases, CD-ROMs).

MedReach provides access to OhioLINK (the statewide library and information network) and its Electronic Journal Center with selected full-text from more than 600 biomedical journals, as well as its health sciences databases that include MEDLINE, CINAHL, and PsycINFO. In addition, computerized full-text databases and CD-ROMs as well as other local library resources, such as the computerized catalog Online System for Library and Educational Resources (OSLER), are available. Articles, books, or literature searches can be requested online from the Mulford Library as well. The Website also includes information for students and a calendar of events in northwest Ohio with a description of upcoming conferences. The medical full-text databases and CD-ROMs currently include: Harrison's Online, Quick Medical Reference (QMR), STAT!Ref, Electronic Library of Medicine (MAXX), and MD Consult, which has recently been added to the resources available on the AHEC Web pages and has become the most widely used resource.

A unique aspect of the MedReach system is that users are able to receive personal help with information retrieval by contacting MCO's outreach librarian. The librarian received approximately seventy-five telephone calls in 2001. About 80% of these calls came from sites stating the computer was not working properly, and 20% came from physician preceptors who were experiencing technical problems or problems with their MedReach account. The outreach librarian makes quarterly visits to each site to provide training in the use of new information resources and to troubleshoot technical problems. Periodically, the MCO AHEC program also conducts an educational program in the medical applications of computers for regional practitioners. The program consists of sessions on utilizing medical information resources from electronic databases, including MEDLINE, CD-ROMs, and Internet sources.

TECHNOLOGY

The concept behind MedReach was to provide access to medical information and databases to physicians and other health care providers throughout northwest Ohio. One way to accomplish this was to make the information resources available through the Internet. To implement this service, the clients were required to have Internet access, and a Web interface to the medical information and databases was provided.

Gateway 2000 computers with Netscape Navigator and Internet access have been configured and installed for MedReach clients. If a hospital or clinic did not already have Internet access, a modem and an Internet service provider account were supplied to them. On the server side, MCO's Internet server, www.mco.edu, is used as the point of contact with the Internet. The Web pages that provide the interface to MedReach are available for the world to see; however, all the medical information and databases are not. Because the information is licensed, it is necessary to develop security for the system. Clients coming from outside of MCO's network need to provide usernames and passwords to access the data.

QMR and MAXX are on CD-ROMs that use a Windows interface. To access them through the Internet, CCI implemented a Citrix WinFrame server that allowed standard Windows applications to run in a Web browser. WinFrame allows clients to start the QMR or MAXX interface on the Citrix WinFrame server and sends user interface, keystrokes, and mouse movements to client computers. The database software runs on the server. Once the server obtains the information from the database, the server sends the necessary information over the network to clients.

STAT!Ref is a Web-based database. WinFrame is used to access the application in a manner similar to the QMR or MAXX products. The Citrix WinFrame server runs a Web browser and connects to the Microsoft Web server (IIs) where STAT!Ref resides.

Harrison's Online and OhioLINK are databases hosted on servers external to MCO. Clients using computers that are not on MCO's network cannot directly access these databases. To compensate for this, users log in to MedReach and WinFrame. They start a browser session that runs on the server and allows them to access Harrison's Online and OhioLINK.

MD Consult is also hosted on a server external to MCO with its own username and password security. The AHEC Website simply provides a link to the MD Consult Web pages. Users have a separate username and password that they must enter once they are on the MD Consult Website. To avoid confusion for those clients coming in from outside of MCO's network, this password is the same as their MCO password and their username differs only in its format.

Each application on the Citrix WinFrame server is associated with a file service, which has a maximum number of connects. This allows control of the number of licensed users for each database.

COMPUTER TRAINING

Education is a critical part of the MedReach project. Clients are not able to make use of the system unless they have the necessary computer and database searching skills. Although many physicians who attend the educational program own personal computers, their skills in using them are not well developed. According to Marshall, the strongest predictor of personal commitment to use of computer-based information gathering is perceived complexity [13]. Therefore, if physicians are not computer literate and perceive computers as being complex and difficult to use, they are unlikely to use them to find information.

Through the collaborative efforts of the Office of Rural Health and AHEC, the MCO's Mulford Library, and the Center for Creative Instruction, an educational program titled “Medical Applications of Computers” has been created. Since 1995, the program has been held every six months at an AHEC or other regional site. Between five and fifteen physicians or health care professionals have attended each program. It consists of didactic materials, case presentations or demonstrations illustrating various computer techniques and applications, and hands-on experience for participants. The teaching faculty has been composed of clinicians, computer specialists, and, primarily, staff of the Mulford Library. The program has been offered free-of-charge and participants receive continuing medical education credits for each session they attend.

Because the program requires some experience using personal computers and knowledge of Windows software, a session on computer basics is held prior to the beginning of the program for participants who lack basic skills and request such a class. The subsequent program consists of four two-hour sessions on a weekly basis. The sessions are held onsite at a local hospital or other facility with Internet access and enough personal computers, so that all participants can have hands-on practice. Sessions are held in the evening when more physicians are able to attend.

Subjects covered in the program include: an introduction to the MedReach system, the Web, medical resources on the Web, Mulford Library resources, OhioLINK resources, and full-text databases and CD-ROMs. A binder with articles, brochures, guides, and bibliographies on all subjects covered in the program is provided to each participant. A clinical case is used throughout the program to help demonstrate how the system can be used in a real world scenario. Various general interest or “fun” Websites are also demonstrated at the end of each session to pique participants' interest.

The first session in the program is an introduction to the system, including the ways to get connected with a local Internet service provider, a description of the AHEC program, and a demonstration of the AHEC home page as well as system help and the online training manual. This session also introduces the Internet and the Web. Specific topics covered include Web browsers, email options, search engines and meta search engines, and plug-ins and downloading.

Medical resources on the Web are covered in session two. Links to medical Websites, medical resource guides and Internet tools, clinical practice guidelines including Agency for Healthcare Research and Quality (AHRQ) guidelines, patient education, online continuing medical education, and discussion groups and email discussion lists are covered in this session.

Session three includes MCO and Mulford Library resources. Topics include the MCO home page, the library home page, the library's online catalog OSLER, the statewide higher education library network OhioLINK, and the online health sciences databases such as MEDLINE. Session four covers the library's medical full-text databases and CD-ROMs.

EVALUATION

Throughout northwest Ohio, there are currently nine remote sites with computer workstations at medical facilities and four remote sites with computer workstations at student housing. One site is in inner-city Toledo and the other sites are in a fifty-to-seventy mile radius surrounding Toledo. One hundred and twenty individual users have obtained usernames and passwords to access the restricted resources of the MedReach system from their homes or offices. Although a systematic survey of users has not been conducted, continued interest in and use of the system is evidenced by anecdotal information, Web usage reports, requests for accounts, requests for assistance, and requests for and attendance at educational programs.

Physicians have stated in conversations that they mainly access the system from their homes, because they do not have time to search databases for medical information during working hours. At sites where computers are available, medical students are asked about the MedReach system in their course evaluations. Between July 2001 and December 2001, ninety-four students were asked whether they found the system useful. Nineteen percent of the students strongly agreed with the statement, 36% agreed, 23% neither agreed nor disagreed, 4% disagreed, and 3% strongly disagreed. Students who disagreed stated that the computer was too slow or that it did not work.

Between June 2001 and November 2001, the AHEC home page received approximately 800 hits per month. The library resources page received approximately 110 hits per month. Unfortunately, because the CD-ROMs (e.g., Harrison's Online, STAT!Ref) are shared with patrons of MCO's Mulford Library, usage by MedReach clients cannot be determined. In addition, statistics are no longer obtained from OhioLINK for MCO clients only. The last time these data were received, however, MEDLINE was accessed about two times per day. Statistics from MD Consult indicated that it has been used an average of sixty-five times per month. In fact, the addition of MD Consult has approximately doubled the usage of the system. Based on these crude statistics and anecdotal information, most of the physicians are using the MedReach system to access MEDLINE or MD Consult.

Feedback on the educational program has been very positive. Twenty-four physicians and two other health care professionals attended the three educational programs offered in 2000 and 2001. Participants of the program rated various aspects of the program as good or excellent. The particular aspects included the content and quality of the program, the presentation and use of teaching aids, the opportunity for hands-on use of computers, the management of questions, and the opportunity for discussion. In general, 78% of the participants thought session one (introduction to the system and the Web) was excellent; 65% thought session two (medical resources on the Web) was excellent; 84% thought session three (library services and databases) was excellent; and 82% thought session four (full-text resources) was excellent. All of the participants somewhat or strongly agreed that the course improved their understanding of medical resources available through computers. They also thought that the information presented in each of the sessions would be practical or very useful in their practice. One physician gave a specific example of how he had used the system to locate a specialist for a patient.

DISCUSSION

MedReach is an ambitious attempt to provide timely, convenient access to medical information resources for physicians and other health care practitioners in northwest Ohio. The Web-based system is easy to use and available at any time of the day to anyone with Internet access. Feedback about the system, the AHEC Web pages, and the educational program has been positive, but improvements can always be made, and upgrades are necessary and beneficial as technology changes.

Usage of the system has been lower than anticipated, probably due to a number of factors. Searching for medical information via computers is certainly still not the norm. Although computers provide access to an overabundance of up-to-date information, many physicians still find it more convenient to read a textbook or journal. Individuals may lack knowledge of the use of computers, or a computer may not always be readily or immediately accessible for information retrieval. With the current pressures to see higher volumes of patients, many physicians also do not have the time to access computerized information. Therefore, they may ask librarians or members of their office staffs to search for information for them. Although the educational program in the medical applications of computers has been developed primarily for physicians, nurses and office managers have expressed an increased interest in it. Time is an even greater barrier for individuals who are computer novices. Not only do they not have time to search databases, they do not have time to attend classes to learn how to use computers effectively. It does appear, however, that individuals who attend the educational programs and updates on MedReach are the ones who more readily use the resources.

As the application of technology becomes more extensive in the provision of health care (e.g., computerized medical records), physicians will become more computer literate and willing to use, or even expecting to use, computers to access medical information. Greater promotion of MedReach needs to be done to increase awareness and use of the system. The system's effectiveness will increase as a method for making timely medical information available to health care practitioners in remote locations, as individuals gain more experience using computers and the Internet continues to expand.