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Issues in Orthopaedic Informatics PDF Print E-mail

J.F. Myles Clough, M.D., FRCSC
Kamloops, BC

Informatics is the study of the use of information. Since most medical subjects, such as orthopaedics, deal with an overload of information, it is unfortunate that informatics is a neglected area. Most of our research effort is put into accumulating more information; in contrast, this article rather focuses on the need to use the information we have already produced in a more fruitful, objective and scientific way.  

In the introduction to Guide to Medical Informatics, the Internet and Telemedicine (http://www.coiera.com/) Enrico Coiera makes the following summary of the scope of medical informatics:

"These then, are the challenges for medicine. Can we put together rational structures for the way clinical evidence is pooled, communicated, and applied to routine care? Can we develop organizational processes and structures that minimise the resources we use, and maximize the benefits delivered? And finally, what tools and methods need to be developed to help achieve these aims in a manner that is practicable, testable, and in keeping with the fundamental goal of health care - the relief from disease? The role of medical informatics is to help develop a rational basis to answer these questions, as well as to help create the tools to achieve these goals."

If that is the framework of informatics, what might be the most vital issues to face up to in Orthopaedic Informatics (OI) and in particular, OI on the Internet?

1. Defining Orthopaedic Subject Matter
Orthopaedic Informatics faces the task of defining and codifying orthopaedic subject headings. This is a "housekeeping" issue but none the less vital. Orthopaedics is full of synonyms and acronyms. But to search electronically one needs an internationally agreed, unique name or code to be added to every piece of information on that subject. Only then can one rely on searches to turn up all the information one is looking for. Creating the code system may not be as difficult a task as securing universal agreement to use it.

2. Creating an Index of Orthopaedic Information
In a recent publication, Johnson & Clough estimated the size of the Orthopaedic Internet as over 100,000 pages. Locating this information, much of which is of high quality, is a difficult, skilled task. It would be highly desirable to have a comprehensive index of addresses of such pages. Both the size of the task and the temporary nature of many web sites complicate the creation and maintenance of such an index. An interactive database to which all orthopaedic surgeons can contribute would be the most feasible structure. Orthopaedic Web Links (OWL) (www.orthopaedicweblinks.com) has been set up to meet this need. To succeed, OWL must solve many complex problems and secure the cooperation of large numbers of orthopaedists, encouraging them to use the index and contribute to it.

3. Integrating 'The Literature' With the Internet
The journals are the most experienced institutions when it comes to high quality orthopaedic information. Many of them have now moved to post a full text version of their "papers" on the Internet but try to support their subscription base by requiring a high price for access to this information. As this changes, the nature of publication is likely to change as Internet-specific features bear fruit. These features include faster turn-around time, integration of feedback into the work and the ease of updating. Those interested in informatics will be trying to hasten and smooth this transition.

4. Evidence Based Medicine
The Cochrane Collaboration (www.cochrane.org) is dedicated to "Preparing, maintaining and promoting the accessibility of systematic reviews of the effects of health care interventions". This site contains abstracts of the meta-analyses prepared by different focus groups. The Cochrane Back Group has undertaken 21 reviews on surgical and non-surgical methods of relief of back pain and whiplash; the Cochrane Musculoskeletal Group has 46 reviews, mostly of nonoperative interventions; the Cochrane Musculoskeletal Injuries Group has 46 reviews and there are some studies from the Pain Group and the Wounds Group which are relevant to orthopaedics. This is really the heart of Orthopaedic Informatics and we should be promoting comparable analyses of many more orthopaedic subjects.

5. Documentation
Information technology now allows us to use outcome systems that are incorporated in day-to-day documentation. This can vastly improve the quality of information we can get from our own practice. Making it easier makes it possible.

6. Defining and Assessing the Quality of Orthopaedic Information on the Internet
There are at least three levels of quality assessment that may be desirable. The first would be provenance, the second content coverage and the third the quality of that coverage. The "provenance" quality is most easily assessed. Silberg et al. (1997) proposed the four criteria of authorship, disclosure, attribution and currency. While these are important, it remains true that a site could satisfy all these criteria and still be rubbish. Clough & Oliver (2002) proposed that orthopaedic patient information pages on the Internet should cover a set of topics relating to the condition, nonoperative treatment, and operative management. However, even if those topics are covered, there is no certainty that they are covered well. Informatics faces a huge task defining and assessing quality. It will involve the creation of standards, the assessment of pages against those standards and some form of "enforcement" of those standards.

7. Learning and Teaching the Skills of Searching
While most people are satisfied that they can use Internet search engines and can find publications on Medline, the truth is that using these assets is a learned skill. It is easy enough to find something on the subject but much more difficult to be sure that the search is comprehensive and doesn’t overload you with extraneous material. Learning to frame your searches that include all you need and still leave you with a manageable number of citations takes time and effort. We need to convince people it is important to learn these skills and we need to teach them how to do it.

8. Paradigm Shift from "Keeping-Up" to "Just-In-Time Learning"
There was a time when one could believe it possible to keep up with developments in orthopaedics by reading one or two of the most reputable journals and going to a conference or two every now and again. The Medline database now includes 102 journals whose main subject is orthopaedics; it would take 70 days a year of continuous round the clock reading to skim that amount of work. So those who claim to "keep up" must be deeming a huge proportion of the world’s orthopaedic scientific effort as unworthy of their attention. Computer based information technology now allows another model for pursuing evidence based medicine. If we were all properly trained and all the information was accessible, we could assemble and study the information on a new subject when we needed it, without having to learn it ahead of time and trust to memory.

9. Developing "Push" Technology
"Push" technology implies devices that send you the type of information you need when it becomes available, rather than leaving you to search. Obviously there are issues of definition of areas of interest, of the comprehensiveness of information sources and the fear of missing some interesting areas because you didn’t foresee them. But this is still a valuable potential weapon in the battle to keep current without being overloaded. We need to develop user-friendly push technology systems in orthopaedics

10. Multi-Centre, Community Based Research through the Internet
For obvious reasons, most orthopaedic research is done in academic centres. Yet the results must be applied in community orthopaedics across the country. Improved communication via the Internet offers research opportunities for all orthopaedic surgeons. This would improve the relevance of the research results and the acceptability of those results to community orthopaedists. It would keep those of us who practice outside academia involved with advances in our subject. The role of OI is to design research protocols taking this into account.

11. Developing a Worldwide Orthopaedic Network
The experience and information needs of the international community of orthopaedic surgeons exemplified by "Orthopod", the largest orthopaedic mailing list, results in two-way learning. The challenges faced by many of the third world surgeons and the ingenuity with which they meet them is most educational. It is clear from these exchanges that there is a tremendous thirst for information and discussion about our subject. Orthopaedic Informatics faces the tasks of listening to these colleagues and of providing a forum for discussion and a resource base of information suited to their practice environment.

12. Guidelines for Tele-Orthopaedics
We have always been able to review information (e.g., x-rays) about a patient we may never see. The new element that computer networks have introduced is speed. While this is desirable, it does mean that remote consultation is being applied to real-time problems; in other words, clinical decisions are being made on the basis of tele-orthopaedics. For the protection of our patients and to safeguard the standards of practice, we need to evolve guidelines appropriate to this reality.

13. Integrating E-mail into Orthopaedic Practice
E-mail offers the opportunity for direct communication among physicians and between patients and their physicians. There are several advantages to communicating by e-mail over telephone communication. At the same time, there are concerns about confidentiality, about invasion of privacy and being "bothered" by intrusive patients. At another level, there are concerns about offering opinions or updating advice via e-mail without seeing the patient. We need to formulate guidelines to maximize the advantages.

14. Re-Thinking Orthopaedic Education and CME
Those interested in Orthopaedic Informatics not only have to understand, promote and guide the developments taking place in this arena. They also have to interpret them to the orthopaedic community and recommend changes to the educational system that will be appropriate for the future. It is a truism that we "learn to learn", but the new reality is that the methods and modalities of learning are changing as well.

15. Understanding and Predicting the Changes
Each of these developments may have a small impact on the practice of orthopaedics. Together they amount to a seismic event. As the information revolution continues, the surgeon’s place as the only person who "knows" about orthopaedics will change. We will be the people with enough experience of orthopaedic problems to interpret the knowledge accessible to everyone. That is a huge shift in emphasis.

Many of these issues are inter-related. One cannot search or construct an index without understanding subject headings; one can see how just-in-time learning and "push" technology might go together. It is not the purpose of this article to treat any of these subjects comprehensively or to "solve" any of the problems. The purpose is to point out that Orthopaedic Informatics is a legitimate area of study. Its subject matter affects us all in very direct ways. I have tried to show that Orthopaedic Informatics is the study of what and how we learn, and how we use orthopaedic information.

To date, the agenda for orthopaedics has been set by professors, editors of journals and the organizers of conferences. It is this group that make the choices that affect what we learn about and perceive to be important. They are, in that sense, the standard bearers of Orthopaedic Informatics. Information technology, especially the Internet, is foreign territory to much of this group who have had the tendency to be cautious about adopting its advantages and quick to point out its shortcomings. As a result, there is somewhat of a power vacuum in a very potent area. A new group of people, many of them not physicians, let alone orthopaedists, are determining what orthopaedic information is prominent. We should not allow this to continue by default. Unless we are all wrong about the importance of the Internet as a communication and education medium, these issues of Orthopaedic Informatics must be faced. Recruitment of qualified people to face them is critical.


Clough J.F.M., Oliver C.W.: Annotation. Orthopaedics, Networks and Computers. J Bone Joint Surg 84-B(4):481-485, May 2002

Cochrane Collaboration: http://www.cochrane.org

Coiera E. Guide to Medical Informatics the Internet and Telemedicine (376 pages) Oxford University Press 1997 ISBN 0412757109 http://www.coiera.com

Johnson D., Clough J.F.M. The Internet for Orthopaedists Springer (210 pages) 2003 ISBN 0-387-95483-X

Silberg W.M., Lundberg G.D., Musacchio R.A. Assessing, controlling, and assuring the quality of medical information on the Internet. JAMA 1997;277:1244-5.