Computers in Psych

In view of the unprecedented amounts of data being yielded by modern experimental approaches, experimental biology and medicine are becoming increasingly dependent on information sciences. Healthcare workers are finding themselves unable to keep abreast of the knowledge of best practice, which is hidden in the burgeoning mountains of literature, to permit translation into clinical practice¹. Medical informatics (also known as bioinformatics) is becoming an increasingly important provider of the necessary tools and resources². Medical informatics is the study of how medical knowledge is created, shaped, shared and applied. It is about communicating the new knowledge, and helping others to understand, apply and adapt it¹.

Medical informatics in healthcare can be divided into information and communication systems. Information systems include the electronic medical record, passive and active computer-based protocol systems and coding and classification database systems. The communication systems can be subdivided into voice telephony, video-conferencing and the Internet. Telemedicine (also known as telehealth) involves the transmission of data in the form of images, voice and text using telecommunications to provide medical services between health units. The definition includes videoconferencing and the Internet as media used in telemedicine. Usually it is used to refer more narrowly to computer or video conferencing. Certainly, the uses of the Internet in medicine are similar to those of videoconferencing: clinical advice, consultation, peer support, education, training and research. The primary objective is to enhance access to and equity of health services and resources, by enabling real time but remote storage and sharing of information^3,4. Australia has become a world leader in telepsychiatry, using videoconferencing to provide mental health services to the outback⁵. Despite initial scepticism, the response has been almost universally positive^6,7.

Coiera, an Australian medical graduate with a PhD in computer science, widely acclaimed as an expert in medical informatics, predicted that the rise of the Internet would have such a massive impact on healthcare delivery in the future that it will become the primary instrument of informatics. He suggested that it is because of the convergence between information and communications systems—that they are starting to become indistinguishable from one another—that technologies such as the Internet are proving to be so revolutionary¹.

Features of the Internet and World Wide Web

The Internet represents the next evolutionary leap in information/communication technology since the printing press was developed⁸. It arose from a cold-war military research project in the 1960s in the United States, to enable computers to communicate with one another as a means of ensuring communication lines remained open after a nuclear strike. It became a global network in the 1980s, used by academic institutions to exchange information.

In 1980, Tim Berners-Lee designed the WWW by developing a formatting language called HyperText Markup Language (HTML). The aim was to deal with information in a "brain-like way"⁹. The user jumps between data by activating hyperlinks—clicking on them with a ‘mouse’ (manual pointing device). Hyperlinks may be words, sentences or pictures that invite the sampling of further information. This associative method is unlike any traditional literary form. The power of hypertext for changing how we interact with information became apparent when the WWW was connected to the Internet in 1991. A global associative web of interlinking multimedia files was formed. There are parallels with psychiatry’s biopsychosocial model, in the non-linear interaction of data occurring in both systems.

The Internet proved to be a technological, social, commercial and enterprise phenomenon. It is an enjoyable, interactive and useful means for easy and rapid communication. It is also the most powerful instrument for the creation and dissemination of information yet created⁸. Information can be created in one place and made available everywhere, realising Berners-Lee’s goal of its becoming "a pool of human knowledge"¹⁰. No physical, financial or cultural boundaries are recognised by information distributed by the Internet¹¹.

Ease of accessibility and rapid communication

Probably the most relevant feature for the resource was the Internet’s provision of ease of accessibility to the database. A standard telephone line connected to a computer permits access for the cost of a local telephone call. Distance becomes irrelevant^11,12. Computers have become cost-effective, acceptable and ubiquitous as a home and work appliance. The database can be accessed in complete anonymity. The information can be disseminated rapidly, such that medical communities living in rural and remote locations may obtain immediate access to up-to-date information. Like video-conferencing telemedicine, it may reduce the isolation of rural doctors and their families. Isolation is a considerable source of stress and limiting factor of remote doctors’ access to peer review and continuing education activities. Rural doctors’ family members are rapidly taking up the benefits of Internet access by ‘getting connected’¹³. Statistics obtained by the Doctors’ Health Advisory Service in NSW (DHAS) indicated that family members make one in ten of their referrals¹⁴.

Interactivity

Hypertext linking between information increases the ease and speed with which the reader can locate relevant material¹⁶. They have the freedom to control the type and amount of information accessed. Providing built-in cross-references does not disrupt the flow of information and offers the choice of gaining deeper knowledge of a particular subject or sticking with an overview¹⁶. This allows the reader take the pathway that minimises over technical or complex terrain, maximising information comprehension.

Graphical interface

The WWW has become the interface to the Internet¹⁵. The bringing together of pictures and text into a coherent work enhances the author’s ability to convey information¹⁶, makes the acquisition of the information more palatable, and markedly facilitates comprehension, learning, memory and creativity because of its iconic presentation¹⁷. Multimedia—the incorporation of moving pictures and sound—adds a further dimension. It is surprisingly easy to use, with all Web pages having the same basic structure, enabling access to many different information resources using the same, familiar user interface¹⁶.

Dynamic versus static content

The Web is dynamic, in a constant state of flux. Aside from the new sites being developed, many existing Web sites are regularly being updated, augmented and refined. This is promoted by the ease of revision. Sites may be purposefully kept static to keep the information on them reliable, consistent and familiar. Familiarity permits the user to become accustomed to the structure and find data more easily each time they return to the site, but information can be potentially always up-to-date. Where older versions of data need to be kept, some Web sites maintain archives that can be accessed¹⁸. Electronic publishing can partially overcome the delays in traditional forms of publication, without necessarily having an adverse effect on the process of peer review¹⁶. With the cost of publication low and ease of publication high, there is a large amount of information on the Internet that is unavailable elsewhere¹⁸.

Monitoring and evaluation

The HTML formatting language can allow the Webmaster to collect statistics about who is using the service, when, and what content is accessed most often. An e-mail address and/or online feedback form may encourage constructive feedback. This may guide subsequent versions of the pages to the requirements of the audience. This permits a unique two-way interaction. It is also possible to monitor the number of links other Web sites have created to the resource¹⁶. Thus the medium has a built-in method of monitoring for outcome evaluation.

The Internet in medicine and psychiatry

Because healthcare is heavily reliant on collaboration and sharing information, but is burdened by an ever-growing body of data, the Internet is shaping up to become a fundamental tool at all levels¹⁰. No other publication medium can cope with the rapidity of change of such material¹⁸. Healthcare providers can benefit from the Internet as a vehicle to obtain up-to-date advice on preventative medicine, specific local support groups and information of value to patients. Consumers use the Internet to obtain assistance from Web sites (informational), news groups, Internet relay chat rooms and mailing lists (communicative)¹¹. An interesting use of the Internet in psychiatry is the indexing of individual practitioners. For example, the Clinicians Yellow Pages¹⁹lists over 1,089 psychiatrists, psychologists, social workers, psychiatric nurses and qualified psychotherapists working throughout the United States.

The explosion in the use of the Internet has occurred so quickly and is now so widespread that it is outstripping healthcare coordinating activities²⁰. Mental health resource Web sites are flourishing on the Internet, although at present they are largely consumer-orientated. Patients are increasingly searching the Internet for the latest information on their disorders and treatments. Ease of access is likely to promote their education and empower patients to take a more active role in their own treatment. This has been predicted to shift the axis of the doctor-patient relationship towards a more balanced position^11,21.

However, the authority and value of online educational resources is difficult for the public to assess. Apart from reliance on reputation and sponsorship from trusted institutions, more formal methods of assessing Internet-based medical resources are being developed¹¹. For example, the Swiss-based Health On the Net Foundation developed a Code of Conduct to promote the accountability of educational sites². Mental Health Net claims to be a Web based organisation committed to rating the quality of the mental health online resources that it indexes²². A number of these organisations aim to educate the public, promote collaboration between mental health professionals, improve access to information about mental health services, encourage research, catalogue online resources, provide continuing education courses online, and review Internet resources for relevant and useful content.

It is increasingly common for medical organisations to create their own sites, where one can discover details about their members’ activities, interests and their staff. It is often possible to correspond by e-mail to members who have specialised expertise¹⁸. Academic departments and evidence-based medicine collaborations are using the Internet to provide up-to-date information about mental health topics to mental health professionals. There are growing numbers of personal Web sites being developed by individual psychiatrists, containing resources for patients and colleagues. Examples are Depression Central²³and Psychopharmacology Tips²⁴. Web site collaborations are encouraged by the medium. For example, a Computers in Mental Health Web site²⁵was developed by the Royal College of Psychiatrists (UK) together with a university department and non-profit organisation, InterPsych, which encourages interdisciplinary debate, collaboration and use of the Internet in psychiatry by academics and clinicians. The International Society for Mental Health Online has a similar mission²⁶.

The Internet offers the possibility of rapid dissemination of research findings and ease for professionals to confer, collaborate and exchange information across disciplinary and geographic boundaries using mailing lists and news groups. All the major psychiatric journals are available online, with powerful ‘search engines’, permitting the user to gain instant access to articles grouped by author, topic or key word. Some engines permit searches of multiple journal databases (such as that of the American Journal of Psychiatry) or allow instant collation of all articles that have been cited by a particular author or article (for example, the British Medical Journal). Hypertext permits references to be linked to original works, which allows a more critical reading of the literature¹¹. Other advantages include speed of publication, reduced costs, the addition of multimedia¹¹, and opening up the peer-review process to the journal’s readership (e.g. the Medical Journal of Australia)^18,27. The amount of peer-reviewed medical knowledge on the Internet is increasing. Some argue that the paper journal is a dinosaur about to become extinct^28,29.

Examining existing Web site resources was a necessary component of the review process in developing an online resource. Additionally, due to the nature of the resource, there was valuable information available online to be utilised. There are two main problems associated with using (and citing) online sources. Firstly, their constant revision may ensure they are up-to-date but makes Web page contents ephemeral^30,31. Information is not seen to be permanent on the Web. A database can be published incomplete. Knowledge is recognised as transitory and dynamic—awaiting to be superseded¹⁸. Thus the Web site resource could be established with less than the four strategy documents having been completed.

Longmore questioned: "If the research communication I am referring to can be constantly changed and is perpetually provisional, what am I referring to? …[There need to be] fixed points of reference"³². McKenzie noted that the ability to consult references exactly as cited is considered paramount to the process of peer review³³. To permit access to versions cited, revisions need to be dated, the contents archived and the documents made retrievable. It is a rare but growing occurrence for Webmasters to archive their Web page versions. Many Web pages now include ‘last updated’ statements, making it easier to identify the version accessed.

Secondly, the rigour of scientific studies published online has been criticised due to the possibility of absent peer review. The practice has been argued by some as threatening "to undermine time-tested traditions that help to ensure the quality of the medical literature"³⁴. However, online publishing does not need to automatically imply the absence of peer review³³. In fact, some journals are undertaking more extensive and ‘democratic’ online peer review processes²⁷, where submitted articles are made available for online review by readers, rather than depending solely on the journal’s expert panel of reviewers.

McKenzie noted in 1997 that "electronic citation is an issue critical to the development of the Internet as a viable tool for scientific medical communications"³³. He proposed that electronic sources could be accommodated by minor changes to both the Harvard and Vancouver reference citing systems. An authoritative method of citing online sources has been developed by both the International Organization for Standardization (ISO) and the Commonwealth Government of Australia. The notation is similar to the citations McKenzie used. AusInfo (previously known as the Australian Government Publishing Service) is a branch of a Commonwealth Government agency that developed an Australian Government Style Manual. Its roles are to disseminate and facilitate online access to government information, and advise on style and standards^30,35.

The reference notation used to cite an electronic document, as reported in AusInfo’s ‘Little book of style’³⁰, is:

Primary responsibility for contribution. Title of contribution. Primary responsibility for host document. Type of medium. Edition. Issue designation. Place of publication. Publisher. Date of update/revision. Date of citation (for online documents). Series. Numeration within host. Location within host. Availability (e.g. URL) and access

When citing World Wide Web documents, the reference is usually expressed as:

Author’s name. Title of document. <URL:address>. Date [and place] of document. (Accessed: date accessed).

In its Information Privacy Code of Practice, the NSW Health Department acknowledges that the Internet is an efficient and cost-effective method of transmitting and accessing information, but notes the community concern about privacy, confidentiality and security issues surrounding its use in healthcare³. There are also questions of legal liability, authenticity of the electronic data and the effects on the doctor-patient relationship^4,11,33,36. The electronic environment may heighten the potential for exploitation and misuse of medical records due to the medium permitting access to the same information from multiple sites and with an increased ability to manipulate the data³.

These concerns are especially prevalent in ‘online therapy’, a controversial use of the Internet whereby advice is given using e-mail or Internet relay chat. A recent article in Time magazine reported that there are now dozens of Web sites with ‘online therapists’ willing to provide fee-for-service advice³⁶. Online dialogue has been argued to permit anonymity, convenience, easy access for disabled and isolated people, at a reduced cost, discomfort and inhibition for some people. However, it imposes a severe limitation on the formation of a doctor-patient relationship, with the lack of any non-verbal cues causing strong criticism. Security is also a major problem, with there being no way to verify the status of the person giving the advice on the Internet. It is uncertain whether online dialogue would constitute psychotherapy or a professional contract of care. Therapists might be construed as ‘practicing without a licence’ if they provide paid services to a patient residing interstate or overseas. It should be noted, however, that these same concerns were voiced with regard to video-conferencing (telemedicine), which has of late been used to provide clinical care to isolated communities that would otherwise go without any service provision.

Application of the Internet as an information system

An information system is a method for storing and retrieving documents. It refers to a model providing templates so that knowledge and data can be used in a systematic way³⁷. The goal of introducing an information system is to streamline processes whereby we manage specific activities within an environment to influence their outcomes. Choosing an electronic information system allows interpretation of the database within it. Once a model of the user’s needs is conveyed to a computer, relevant subsets of the data can be viewed, matching the interest of the researcher. The model and data need to be sufficiently formalised to accomplish this³⁸. The aim of using an electronic information system by the Implementation Committee was to structure the process of implementation of the guidelines to improve the reliability, efficiency and consistency of the process. There is growing evidence that providing computer-assistance to improve access to clinical protocols does have a positive impact on adherence to guidelines, greater than paper-based reference materials³⁹.

There needed be enough informality that the target audience would have the freedom and flexibility to implement the information in a constructive way into their organisations⁴⁰. Communication systems are commonly used to support informal information processes, because they are so flexible⁴⁰. The Internet thus promised to deliver the best of both worlds. Many now see the Internet as the vehicle of choice for the distribution of clinical practice guidelines. Creating a Web site, as the Cochrane Collaboration have done, allows anyone on the planet connected to the Internet immediate access to the guidelines stored there⁴¹. The Web model of publishing allows a document creator to put the burden of access onto the reader, as it is made available in a known location to all those interested¹⁰.

There are potential drawbacks using the Internet. There are no formal controls on what can be published, resulting in online material of varying standards³⁹. Amidst the rapid change, it is often unclear what is fundamental and what is just the fleeting detail of an evolving technology⁴². The main area of difficulty, however, lies within the culture of medical practice. For example, the application of evidence-based protocols has to some extent been met with resistance by the medical community as some have perceived them to be an intrusion on clinical freedom⁴³.

Sometimes building information systems can be counterproductive⁴⁰. It should carefully be considered whether a health information systems project is possible, practical and desirable. Possibility reflects the science of informatics—what in theory can be achieved. Practicability addresses what can actually be done given the constraints of the real world. And desirability looks as the fundamental motivation for using a given technology¹.

References:

Coiera E. Introduction to medical informatics. In: Guide to medical informatics, the Internet and telemedicine. London: Chapman and Hall Medical, 1997:xxi-xxvii.
Health On the Net Foundation. Background. Report from an international conference, Use of The Internet and World-Wide Web for Telematics in Healthcare, 7-8 September 1995. Geneva: the Swiss Institute of Bioinformatics. (Accessed: 16 April 1999).
Information Management and Clinical Services Branch. Information Privacy Code of Practice. 2nd Edition. NSW Health Department: December 1998; pp37-43, pp51-57.
Hansen K. Telemedicine: take two aspirin and email me in the morning. Australasian Medicine. 1999; 11:10-11.
Hawker F. Telemedicine user network: a call for interested participants. Australasian psychiatry 1997; 5:6:296.
Yellowlees P, Kavanaugh S. The use of telemedicine in mental health service provision. Australasian Psychiatry 1994; 2:6:268-270.
Clarke P, Hafner RJ. Telepsychiatry in South Australia. Australasian Psychiatry 1997; 5:3:124-126.
Coiera E. The Internet. In: Guide to medical informatics, the Internet and telemedicine. London: Chapman and Hall Medical, 1997:243-258.
Quittner J. Network Designer. Time, March 1999:134.
Coiera E. The World Wide Web. In: Guide to medical informatics, the Internet and telemedicine. London: Chapman and Hall Medical, 1997:259-273.
McKenzie BC. What use is the Internet in medicine? In: Medicine and the Internet: introducing online resources and terminology. New York, Oxford University Press: 2nd edition, 1997:107-130.
McKenzie BC. What is the Internet? In: Medicine and the Internet: introducing online resources and terminology. New York, Oxford University Press: 2nd edition, 1997:97-106.
Williams A. Personal communication, NSW Doctors’ Mental Health Implementation Committee, January 1999.
Pullen, D. Personal communication, Doctors’ Health Advisory Service (NSW), February 1999.
McKenzie BC. Utilizing the Internet. In: Medicine and the Internet: introducing online resources and terminology. New York, Oxford University Press: 2nd edition, 1997:149-152.
McKenzie BC. Becoming an information provider. In: Medicine and the Internet: introducing online resources and terminology. New York, Oxford University Press: 2nd edition, 1997:253-264.
Nature Medicine. The Reincarnation of Biomedical Journals as Hypertext Comic Books. Vol. 4, 1998. (Accessed: 16 May 1999).
Coiera E. The Internet, the Web and healthcare. In: Guide to medical informatics, the Internet and telemedicine. London: Chapman and Hall Medical, 1997:277-8.
Mental Health Network. MHN – Clinical Yellow Pages: Search the Database.(Accessed: 16 May 1999).
Health On the Net Foundation. Background and Objectives, International Working Conference on the use of Internet and World-Wide Web for Telematics in Healthcare. Geneva: Department of Health and Social Affairs of the Republic and Canton of Geneva: 12 Mar 1997. (Accessed: 16 May 1999)

Carlile S, Sefton AJ. Healthcare and the information age: implications for medical education. Medical Journal of Australia 1998; 168:340-343. (Accessed: 16 May 1999).
Mental Health Net and CMHC Systems. Mission Statement. Dublin, Ohio. (Accessed: 16 May 1999).
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Hsiung R. Psychopharmacology Tips. May 7, 1999. (Accessed: 16 May 1999).
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Bingham CM, Higgins G, Coleman R, Van Der Weyden MB. The Medical Journal of Australia Internet peer-review study. Lancet 1998; 352:8:441-445.

Coiera E. Medical informatics meets medical education. Medical Journal of Australia 1998; 168: 319-320. Online: Feb 2, 1999. (Accessed: 16 May 1999).
LaPorte RE, Marler E, Akazawa S, Sauer F, Gamboa C, Shenton C. The death of biomedical journals. British Medical Journal 1995; 310:1387-90.
Purchase S (ed.) The little book of style. AusInfo, Department of Finance and Administration, Commonwealth of Australia. Canberra: Paragon Printers, 1998:71.
Littlejohns C, Briscoe M. The information superhighway and psychiatry. Psychiatric Bulletin 1996; 20:146-148.
Longmore M. Permanence of paper puts authors on best behaviour. British Journal of Medicine (letter) 1995; 311:507.
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Kassirer JP. The next transformation in the delivery of health care (editorial). New England Journal of Medicine 1995; 332:52-3.
AusInfo. What AusInfo Does. Canberra: Department of Finance and Administration, 1999. (Accessed 5/05/99).
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This information has been excerpted from my Dissertation: Developing a Doctors’ Mental Health Web Site Resource. NSW, 1999, Royal Australian and New Zealand College of Psychiatrists.

Citation suggestion: Dr Gary Galambos, Computers in Psychiatry, RANZCP Dissertation 1999 (http://www.ep.org.au/gg/int/comp.htm) [date accessed]

The materials provided on this website may be freely cited but reposting on other websites, publishing or other reproductions, whole or in part, are subject to the written permission of Gary Galambos. Images may be reproduced provided the source is properly acknowledged.

CONTENTS:

Medical informatics