Orthopaedic Knowledge: Orthopaedic Information Technology

Author : Myles Clough, MD

Published: 03/29/2001

Introduction

Signs of the growing integration of the Internet into the mainstream of orthopaedic academic activity were evident at the 68th Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS). Queues at the email kiosks, standing room only at the AAOS "Create Your Own Website" display, and packed attendance at the Digital Imaging Instructional Courses all tell their own tale. However, few formal presentations were delivered on this topic, indicating a lack of scientific studies on the impact of information technology on orthopaedic surgery. Areas of particular interest included patient information on the Internet, sites for orthopaedic surgeons, digital imaging, and other uses of the Internet for such things as evaluating outcomes and maintaining databases.

Patient Information on the Internet

One of the most popular areas of investigation is the impact and quality of orthopaedic patient information. Several studies have been conducted to examine how many patients use the Internet to get information on orthopaedic care and to evaluate the quality of that information.

Dr. Terry Messer and colleagues^[1] undertook a 2-part study. In the first part, they evaluated patient information sites on anterior cruciate ligament (ACL) reconstruction and total knee arthroplasty (TKA). They found bias in 59 of 116 sites evaluated and inaccurate information in 25 of the 116 sites. They concluded that 60% of these sites were biased, inaccurate, or both.

The second part of the study involved a survey of Internet use of 200 patients (100 patients with ACL reconstruction, 100 with TKA). Forty percent of the ACL patients used the Internet for information about their condition, as did 14% of the TKA patients. This reflected the age-related differences in Internet use. Patients generally found that information on the Internet was helpful and did not conflict much with the information they received from their surgeons. The study concluded that orthopaedic surgeons should be aware of patients' use of the Internet and should be prepared to guide their patients to sites that are accurate, reliable, and free from bias. Unfortunately, the authors of this study did not give an indication of where such sites are to be found.

Dr. Charles K. Lim and colleagues^[2] presented another survey on how patients use the Internet. They surveyed 500 patients in a general orthopaedic practice and found that up to 77% of younger patients and 16% of older patients used the Internet. Of these, 56.5% use the Internet to obtain orthopaedic health information.

The team also conducted a survey to find out what patients would like to access through the Internet. They found that high numbers of patients would like to be able to email their physicians, and more than 80% would like to access their physicians' Web sites. Concerns were expressed by patients about the privacy and security of their medical information on the Internet.

The authors noted that their study population represented only a small sample in a specific community. In addition, the survey was conducted before January 2000, so Internet use may have changed since then. Despite these limitations, Dr. Lim and colleagues were able to conclude from the studythat patients are increasingly using the Internet for orthopaedic information and are expecting better quality and access to useful information. They urge orthopaedic surgeons to adopt the Internet and integrate it into their patient information strategies.

Dr. Robert B. Koch and associates^[3] gave a presentation entitled "Shoulder Information Available on the Internet: Is It Accurate?" They reported on a study of 120 statements, 30 each about 4 common shoulder problems, that were collected from randomly selected Web sites by a nonmedical person. Five fellowship-trained shoulder surgeons were asked to rank the validity of the statements on a scale of 1 (strongly disagree) to 5 (strongly agree).

The mean validity score was 3.79, with minor differences between the 4 shoulder problems selected (frozen shoulder, 3.41; osteoarthritis, 3.81; shoulder instability, 4.07; and rotator cuff, 3.85).

Examples of statements that were rated as "highly valid" included "Frozen shoulder is often associated with thyroid disease," or "Rotator cuff tears normally occur through areas that are not normal to begin with." Examples of statements rated as "highly invalid" included "Shoulder magnets help pain, swelling, and inflammation and increase the blood flow to the shoulder" (in reference to osteoarthritis), or, "Usually a test called an arthrogram, in which dye is injected into the shoulder, is required" (in reference to rotator cuff tears).

Koch and associates concluded that 20% of the information about management of shoulder problems found on the Internet is misleading and invalid. Physicians should be aware of these inaccuracies to counsel their patients better.

To put these studies in perspective, it is important to apply the same standards and criteria that are applied to the information found on the Internet to the information surgeons normally give their patients. None of the studies presented did this or referred to studies in which this has been done. It is natural to assume that information provided by surgeons is more complete and accurate than that found on the Internet, but this has not been tested and should be.

Improving Orthopaedic Informatics: The Orthopaedic Gateway

Dr. David L. Nelson and colleagues ^[4] presented the "Expanded Orthopaedist's Guide to the Internet." This is part of the Orthogate Project, an attempt to form a clearinghouse for orthopaedic surgery on the Internet sponsored by the Internet Society of Orthopaedic Surgery and Trauma (ISOST). The Guide contains modules on searching the Internet, improving your use of email, setting up your office Web site, imaging, finding commercial orthopaedic information, discussion forums and an appendix of additional reading.

The Internet Society of Orthopaedic Surgery and Trauma is a nonprofit academic society founded in 1999 to improve orthopaedic informatics. It has over 400 members worldwide. Through its Orthogate site, it pursues these aims by providing a collection of links to orthopaedic sites of interest and access to Web-based mailing list archives that promote communication among orthopaedic surgeons on a variety of topics.

Digital Imaging

Digital imaging is an area of keen interest in orthopaedic surgery. Several presentations were devoted to this topic. At the Instructional Course Lecture (ICL) on "Digital Imaging and Computer Presentation,"^[5] moderators J.W. Brodsky and R.W. Sanders presented useful information on image capture using digital cameras and other devices, but information was lacking on editing of digital images after they have been captured. The focus was on using images for presentations, whereas most orthopaedic surgeons can expect to use images more often for clinical records and for sending them to colleagues. Nevertheless, the introduction to the PowerPoint program for presentation and the tips and pointers shared with the audience were valuable. About half of the participants brought their laptops so they could participate more fully in the workshop.

The presentation on "Computer-based Multimedia Presentations - the Essentials"^[6] also demonstrated the techniques for PowerPoint presentations. About 50% of the podium presentations at the meeting used PowerPoint rather than slides.

Dr. Brett M. Andres and associates^[7] presented a review of results that can be expected from using a digital camera for clinical imaging. They compared 4 cameras and assessed their effectiveness with regard to plain radiographs, cross-sectional images (eg, CT), operative specimens, and a knee simulator. The quality of the output was compared, and they concluded that the image should contain at least 2.1 megapixels to provide sufficient resolution; storage medium should be removable and have space for at least 20-30 images; the zoom system should be optical, not digital; macro mode should have a focus of less than 12 cm (5 in); and high-speed transfer of images to a computer is best achieved using a USB port or Flash cards. However, for sharing images with others, transfer by floppy disk is a good option because it doesn't require special programs or hardware.

Dr. Troy Watson^[8] presented a scientific exhibit on digital imaging. He also compared several systems and concluded that use of a digital camera is the most suitable method. He reviewed a number of topics, including how to choose a camera, how to use a digital camera, computer needs, mechanisms of image transfer from camera to computer, image storage media, and archiving systems. Dr. Watson also provided a review of resources available in print and on the Internet. Unlike most of the other displays on imaging, his presentation emphasized the need to edit the image before storing it, and his focus was on using images for everyday clinical practice rather than for academic presentations.

The ISOST Guide describes 5 ways of capturing images: video capture, use of a scanner, digital camera, digital arthroscopy systems, and digital radiology. Use of a digital camera is probably the optimal choice if the budget allows because it is the most versatile.

Gomoll and Thornhill^[9] presented a solution to the problem of storing and indexing scanned and digital images, documents, presentations, and video segments in a teaching and research environment. The image database they described is accessible to contributing members over the Internet and has greatly facilitated the preparation of talks and presentations.

Other Uses of the Internet

Dr. Diana L. Hauser and associates^[10] presented a discussion of the Massachusetts Total Hip Registry, a multisourced, Internet-based database of patient information, surgeons' assessments, operative and follow-up reports, and radiology images. This system reduces to a few minutes the time it takes to collect a cohort of patients who satisfy certain inclusion data.

Strain and Kurzon^[11] identified a rich source of outcomes data that has been largely overlooked. Physicians input volumes of data into billing systems. So far only invoices and other financial reports have been generated from these data. With some additional effort, these data can be transformed into information on outcomes and performance measurements, specifically operation and reoperation rates for certain diagnoses, requirements for postoperative physiotherapy, number of visits related to diagnosis, referral rates, and requirements for other services. The authors have set up templates of commonly used database and spreadsheet programs that clinicians can use to obtain comparative information on their own practices.

Mohtadi and colleagues^[12] wanted to determine whether outcomes questionnaires administered through a computer system displayed any inherent bias, and how well they were tolerated by patients. They found that there were more problems with the paper format (eg, unanswered questions, which were not permitted with the computer system). No significant differences in the scores were found for most groups, and there was no evidence of a patient preference for paper, although the study lacked sufficient power to prove that the lack of difference found between the groups was statistically significant (see Tornetta and associates^[13]). Despite this limitation, the study concluded that computerized questionnaires for quality-of-life measurement can replace paper without loss of accuracy.

AAOS Web Site

The AAOS had a special display area at the meeting to acquaint members and other attendees with services available on their Web site. This display was staffed by orthopaedic surgeons from the AAOS Internet Committee and from ISOST. One feature was a facility where attendees could create a Web site for their own practice. This is available, free of charge, to all AAOS fellows, members, and international affiliates. The site, which is password protected, is template-based and allows the surgeon to describe his or her practice under the headings of Educational Background, Board Certification and Focus, Office Location & Hours, and Affiliations. The AAOS site has been recently upgraded to facilitate navigation to the enormous variety of information on the site. A series of pop-up menus on the front page allow immediate access to the Patient Information Site (which contains information about hand, neck, shoulder, spine, hip, arm, knee, and foot fractures), Medical Education, Annual Meetings, Academy Journals, Orthopaedic Yellow Pages, and an Educational Resources Catalog.

General Comments

The focus of orthopaedic informatics research on patient information is highly appropriate and needed. Orthopaedic surgeons who are trained to evaluate the quality of information obviously need less guidance than their patients do. A letter to the editor that appeared in JAMA ^[14] pointed out that patients who use search engines to access orthopaedic information on the Internet are likely to find a very mixed collection. Unfortunately, none of the current studies have advanced much beyond this conclusion. The studies presented did not, for the most part, refer to Rose and colleagues or other similar published papers. Although they all concluded that orthopaedic surgeons need to guide their patients, they did not, in fact, provide such guidance or offer links to sites where orthopaedic patients can find information that has been vetted by an orthopaedic surgeon.

The next generation of studies should investigate solutions to the problem, compare the quality of information on the Internet to that obtained from the treating surgeon, and propose mechanisms for securing quality assurance on the Internet. The field is small yet. A MEDLINE search for "Orthopedics [MeSH] AND Internet [MeSH]" yielded only 25 citations on March 7, 2001.

Currently, 2 not-for-profit organizations are offering "solutions" to the problem of quality information on the Internet: AAOS and ISOST. The AAOS provides a very comprehensive database of patient information and encourages its members to use it. Patients and orthopaedic surgeons can be assured that this information is of exceptional quality. ISOST believes that patients will not be satisfied with information from a single source. By assembling links to patient information sites that have been collected by orthopaedic surgeons, ISOST anticipates becoming the clearinghouse for orthopaedic information. If that goal can be realized, reviews by the orthopaedic community that makes up ISOST will carry some weight.

References

Messer TM, Stern SH, Patel AA, Edwards SL. Evaluation and patient utilization of Internet Web sites related to anterior cruciate ligament reconstruction and total knee arthroplasty. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Abstract 067.
Lim CK, Parekh SG, Nazarian DG, Booth RE. Orthopaedic patients on the Internet. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Abstract 070. Available at: http://www.aaos.org/wordhtml/anmt2001/sciprog/070.htm
Koch RB, Lazarus MD, Romeo AA, Williams GR Jr, Jensen KL. Shoulder information available on the Internet: is it accurate? Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Poster 028. Available at: http://www.aaos.org/wordhtml/anmt2001/poster/pe028.htm
Nelson DL, Clough JFM, Sechrest RC, Eaton C. An expanded orthopedists' guide to the Inernet. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Exhibit SE45.
Sanders RW, Brodsky JW, moderators. Digital imaging and computer presentation. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Course 315. Available at: http://www.aaos.org/wordhtml/anmt2001/icl/315.htm
Weil CE, Rooks MD, moderators. Computer-based multimedia presentations -- the essentials. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Course 243.
Andres BM, Khanna J, Wenz JF, Frassica FJ. Digital imaging for the orthopaedic surgeon: current applications and recommended equipment for optimal results. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Poster PE150.
Watson T. Digital photography for the orthopaedic surgeon. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Scientific Exhibit 44.
Gomoll AH. Introduction of a distributed asset management system: an image database for surgeons accessible over the Intra-/Internet. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Poster 153.
Hauser DL, Hoeffel DP, Condon RH, et al. Advanced Web-based Internet site documentation center for outcome studies. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Poster 151. Available at: http://www.aaos.org/wordhtml/anmt2001/poster/pe151.htm
Strain RE Jr, Kurzon JD. Claims data from an outcome database you already have. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Poster 152.
Mohtadi N, Sasyniuk TM, Hollinshead RL. Development and evaluation of preference for a computerized outcome system for prospective outcome assessment. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Poster 154.
Tornetta P, Lochner H, Bhandari M. Type II error rates (beta errors) of randomized trials in orthopaedic trauma. Program and abstracts of the AAOS 68th Annual Meeting; February 28-March 4, 2001; San Francisco, California. Paper No. 066.
Rose S, Bruce J, Maffuli N. Accessing the Internet for patient information about orthopedics [letter]. JAMA. 1998;280(15).

Authors and Disclosures

Author(s)

Myles Clough, MD

Clinical Instructor, Department of Orthopaedic Surgery, University of British Columbia; Orthopaedic Surgeon, Kamloops, British Columbia, Canada.

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CME Released: 03/29/2001; Valid for credit through 03/29/2002

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