Electronic Skills

Searching

Another approach to integrating the Internet with academic orthopaedics has been to explore the results of electronic searching for orthopaedic information.  An early example in 1999 ¹ considered foot and ankle problems and even then noted that 41% of the sites found were commercially oriented. Groot et al (2001) ² also noted poor quality information on ankle sprain and suggested that a search "by an experienced information officer" might be preferable to one undertaken by an orthopaedic surgeon. A more hopeful position is taken by authors detailing searching techniques ^{3 4 5 6 7} and websites to help find useful orthopaedic pages ^{8 9 10} . The focus now is on teaching orthopaedic surgeons electronic skills so that they can find and evaluate useful orthopaedic web pages. Recent workshops presented at the Congress of the Egyptian Orthopaedic Association and elsewhere, stressed hands-on learning of electronic skills. These skills cannot be learned simply by listening or reading.

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. A fundamental part of Orthopaedic Informatics is convincing people it is important to learn these skills and establishing the best methods of teaching them.

Webpages

Posting webpages on the Internet is a simple matter. Most popular word processing programmes allow the user to save a document as a webpage, making the production into a simple secretarial task. Posting a page produced by this means is also a simple matter, requiring a File Transfer Protocol (FTP) programme and the appropriate passwords. Nearly all Internet Service Providers offer space on the Internet for their subscribers so the cost of posting webpages is very low. Many sites also function as databases; registrants can add material directly to the site without any processing. Despite all this, even from academic departments, the  production of webpages with orthopaedic content is sparse ¹⁰ and the quality of the production is low ^{11 12} . The Canadian situation was summarized as follows -
"Web sites should serve the functions of promoting the services of the institution, making two-way communication easier and speeding up information exchange. As information is one of the primary products of an orthopaedic teaching institution, there should be a large role for the Internet. It will require a team effort involving all of the staff.

Orthopaedic Internet activity in Canada is still the province of enthusiasts. While some of these are world leaders in the area, there is little integration of the Internet into the normal modus operandi of major orthopaedic institutions. When that paradigm shift occurs, orthopaedic surgeons, trainees and patients will be better served."

In contrast, webpages associated with orthopaedic practices, clinics or hospitals are now extremely common ¹³ . These sites are posted on the assumption that they increase patient recruitment and they tend to present information, even patient education information, in a "come-hither" way. There has been some research in the primary care situation on the success of this gambit but none, as yet, in orthopaedics. A cost/benefit analysis of practice websites would be illuminating and perhaps surprising. A hand surgeon with an excellent and informative website ¹⁴ estimates that only one patient a year is recruited through his website. He believes the primary role of the practice website is to inform his patients, improve communication and reduce redundant work ¹⁵ .

 Digital Imaging

Orthopaedic surgery is a very visual subject and relies heavily on illustration using images from Xrays, clinical and operative photographs. In many hospitals radiology is now digital and the introduction of digital radiology initially caused problems ^{16 17 18 19} with the provision of clinical orthopaedic services. These problems tend to resolve themselves over time and most clinicians now accept the benefits of digital radiology.
Orthopaedic surgeons have a key role in producing illustrations for teaching, research and archive purposes ²⁰ . The skills need to produce excellent digital images ²¹ include capture, using digital cameras or scanners, editing and archiving ²² . Although the Electronic Skills Pavilion at the Annual Meeting of the AAOS usually covers these topics, little has appeared in the orthopaedic literature ²³ .

Presentation Graphics

Digital presentations (usually using the Powerpoint (TM) format) are now the norm for scientific presentations at orthopaedic meetings and many in-hospital presentations. There have even been suggestions that these presentations will replace journal articles ²⁴ . Although it is common to encounter poor or distracting presentations, attempts to teach presentation skills ²⁵ are few. This may be another subject that can only be taught "hands-on" ²⁶ . ISOST is developing a section of the Orthogate website for hands-on workshops in various electronic skills ²⁷ .

Footnotes

Ref	Notes
1	Nogler M, Wimmer C, Mayr E, Ofner D, 1999. "The efficacy of using search engines in procuring information about orthopaedic foot and ankle problems from the World Wide Web." Foot Ankle Int 20 (5): 322-5 [PubMed] Abstract: This study has attempted to demonstrate the feasibility of obtaining information specific to foot and ankle orthopaedics from the World Wide Web (WWW). Six search engines (Lycos, AltaVista, Infoseek, Excite, Webcrawler, and HotBot) were used in scanning the Web for the following key words: "cavus foot," "diabetic foot," "hallux valgus,"and "pes equinovarus." Matches were classified by language, provider, type, and relevance to medical professionals or to patients. Sixty percent (407 sites) of the visited websites contained information intended for use by physicians and other medical professionals; 30% (206 sites) were related to patient information; 10% of the sites were not easily classifiable. Forty-one percent (169 sites) of the websites were commercially oriented homepages that included advertisements.
2	Groot D, ter Riet G, Khan KS, Misso K, 2001. "Comparison of search strategies and quality of medical information of the Internet: a study relating to ankle sprain." Injury 32 (6): 473-6 [PubMed] Abstract: OBJECTIVES: to evaluate the quality of web sites on ankle sprain diagnosis and treatment and to assess the impact of Internet search expertise on quality of retrieved information. METHOD: two internet search strategies were conducted - one developed by an experienced information officer (expert's search) and the other based on the search terms used by orthopaedic medical staff (doctors' search). RESULTS: the expert's search revealed 32 web sites, of which nine were relevant, whereas the doctors' search revealed 61 web sites of which 27 were relevant. Of the relevant web sites in the expert's search, one complied with all quality criteria, whereas none of the web sites in the doctors' search complied with all criteria (11 vs. 0%, P=0.25). The web sites identified by expert's search had higher credibility (median scores 70 vs. 44, P=0.01) and accuracy of content (median scores 50 vs. 35, P=0.24). CONCLUSION: the quality of medical information on the internet is generally poor and information experts can capture higher quality web sites compared with doctors.
3	Peiper M, Knoefel WT, Junge G, Hosch S, Izbicki JR, 2002. "[The Internet as a source for information retrieval. Example: soft tissue sarcoma]" Chirurg 73 (9): 930-7 [PubMed] Abstract: INTRODUCTION: Due to increasing availability, easier access, and rapid growth of information, the Internet has become an important source of medical information. We analyzed the value of Internet sites and the content of their medical information for physicians and patients using the example "soft tissue sarcoma." METHODS: Sixteen German and English Internet search engines were used to evaluate the retrieved internet sites regarding their target group, publisher, contents, and topicality. RESULTS: The majority of retrieved websites were in English compared to significantly fewer in German. The content of information was more valuable for patients and physicians on the English websites compared to the German ones. Even if many of the evaluated websites originated from medical organizations or universities, the amount of information was limited and often not up to date. CONCLUSION: Information on the web is widespread, but for special queries too limited and difficult to identify. An improvement of available websites is needed, especially those maintained by universities and nonprofit medical organizations. The retrieval software should be optimized to ease identification of information, which should be validated by a recognized standard.
4	Gillespie LD, Gillespie WJ, 2003. "Finding current evidence: search strategies and common databases." Clin Orthop Relat Res (413): 133-45 [PubMed] Abstract: With more than 100 orthopaedic, sports medicine, or hand surgery journals indexed in MEDLINE, it is no longer possible to keep abreast of developments in orthopaedic surgery by reading a few journals each month. Electronic resources are easier to search and more current than most print sources. We provide a practical approach to finding useful information to guide orthopaedic practice. We focus first on where to find the information by providing details about many useful databases and web links. Sources for identifying guidelines, systematic reviews, and randomized controlled trials are identified. The second section discusses how to find the information, from the first stage of formulating a question and identifying the concepts of interest, through to writing a simple strategy. Sources for additional self-directed learning are provided.
5	Smith CG, Herzka AS, Wenz JF, 2004. "Searching the medical literature." Clin Orthop Relat Res (421): 43-9 [PubMed] Abstract: Medical literature searches have become more complex because of the increasing amount of published material and the multiple available databases indexing those publications. Although newly graduated physicians may have received some training in literature searching as part of a medical school curriculum, most clinicians have received no formal training in this skill. In today's world of evidence-based medicine, access to published data is crucial, and the importance of a systematic approach to searching cannot be overemphasized. A brief review of searching techniques can greatly increase productivity while using the MEDLINE, Excerpta Medica, Science Citation Index, and other databases. Similarly, knowing the options available for remote access to databases and electronic delivery of articles can expedite the task of accessing publications.
6	Simpson P, Oliver CW, 2004. "Searching the internet for orthopaedic knowledge." J Bone Joint Surg Br 86 (8): 1105-7 [PubMed]
7	Oliver CW, Veillette C, Clough JFM. Orthopaedic web links (OWL): catalogue of the orthopaedic internet. He@lth Information on the Internet 2002:29:7-10. Available at http://www.ingentaconnect.com/content/rsm/hinfo/2002/00000029/00000001/art00006
8	Orthopaedic Web Links (OWL) Available at http://www.orthopaedicweblinks.com
9	Oncology (Williston Park). 2003 Jun;17(6):768-70. Keeping up with medical information: a Website to help. Biermann JS.
10	COA Bulletin 2000 Two Views of the Future Clough JFM Available at http://www.coa-aco.org/en/library/orthopaedic_informatics/two_views_of_the_future.html [ a b ]
11	Rozental TD, Lonner JH, Parekh SG, 2001. "The Internet as a communication tool for academic orthopaedic surgery departments in the United States." J Bone Joint Surg Am 83-A (7): 987-91 [PubMed] Abstract: BACKGROUND: The Internet's appeal as an affordable, accessible medium for information transfer makes it a potentially useful tool for practicing physicians. In the past several years, Internet-based health-care companies have proliferated, and many medical centers have established individual web sites. The purpose of the present study was to evaluate academic orthopaedic surgery departments in the United States with respect to Internet visibility and content. METHODS: We reviewed existing web sites for the 154 departments or divisions of orthopaedic surgery currently accredited for resident education by the Accreditation Council for Graduate Medical Education. The study sample consisted of the 113 departments that had a web page listed in the FREIDA (Fellowship and Residency Electronic Interactive Database) database. Each web site was assessed with regard to its informational value in the categories of clinical services, resident education, and physician recruitment. In addition, three commonly employed browsing engines were used to search for individual web sites and to determine their ease of accessibility. RESULTS: In the category of clinical services, sixty-five (57.5%) of the 113 sites provided faculty listings and forty-nine (43.4%) provided office telephone numbers and locations. Only thirteen sites provided information on common orthopaedic conditions, and five had links to other patient-education sites. In the category of resident education, twenty-four sites (21.2%) had online academic schedules, but only two provided access to complete conferences or teaching files. In the category of physician recruitment, ninety-one provided a description of their residency program and fifty-four had information on the application process, but only twenty-six web pages offered detailed departmental statistics. In terms of accessibility, fifty-three programs (46.9%) were identified by one of three popular search engines, seventeen (15%) were identified by more than one search engine, and two (1.8%) were identified by all three. CONCLUSIONS: Academic orthopaedic surgery departments in the United States underutilize the Internet as a source of clinical and educational services. In addition, existing orthopaedic web sites are difficult to access with use of popular search engines. Thus, academic orthopaedic surgery departments in the United States are missing a valuable opportunity to promote awareness of their institutions and to become educational resources for the community.
12	Surfing the Canadian Orthopaedic Internet Clough JFM Bulletin of the Canadian Orthopaedic Association 2001 Available at http://www.coa-aco.org/en/library/orthopaedic_informatics/surfing_the_canadian_orthopaedic_internet.html
13	Biermann JS, Golladay GJ, Peterson RN, 2006. "Using the internet to enhance physician-patient communication." J Am Acad Orthop Surg 14 (3): 136-44 [PubMed] Abstract: The rise in Internet use by patients with musculoskeletal problems has put orthopaedic surgeons under increased pressure to provide Web-based resources. Patients are researching musculoskeletal conditions online, and many want to communicate electronically with their physicians. Online medical information may be a useful adjunct to traditional physician-patient interaction because it is readily available, is wide in scope, and can provide the patient with basic knowledge on a given topic. A clinical encounter may then be efficiently spent refining information and answering specific questions. Orthopaedic surgeons should be aware of the advantages of using Internet resources as part of their practice as well as the potential legal and confidentiality pitfalls in electronic communication. Some patient concerns may be easily satisfied and communication enhanced through the use of e-mail. Physicians planning to incorporate electronic communication with their patients must be prepared to manage unsolicited e-mail, maintain patient confidentiality, and adopt practices that maximize the use of online resources to enhance patient education.
14	Dr. David L. Nelson, MD Specializing in Hand Surgery 2008 [Website] Available at http://www.davidlnelson.md
15	Nelson DL Personal Communication
16	Wade FA, Oliver CW, McBride K, 2000. "Digital imaging in trauma and orthopaedic surgery: is it worth it?" J Bone Joint Surg Br 82 (6): 791-4 [PubMed]
17	{COA Bulletin 2001 The Introduction of Digital Radiology - a Survivor's Guide.  Harvey EJ Available at http://www.coa-aco.org/en/library/orthopaedic_informatics/the_introduction_of_digital_radiology_-_a_survivor%27s_guide.html
18	Wade FA, Oliver CW, 2004. "Living with digital imaging." Clin Orthop Relat Res (421): 25-8 [PubMed] Abstract: Increasingly orthopaedic departments are using digital radiology and imaging systems. We review the technical features of a digital radiology system for the orthopaedic surgeon. The pros and cons of digital and computed radiology are discussed. Hardware and software requirements for storage, retrieval, manipulation, and display of digital images are reviewed. The potential benefits to the clinician and the patient are outlined.
19	Fraser-Moodie J, Oliver CW, 2006. "Problems with digital imaging in trauma." Injury 37 (9): 803-5 [PubMed]
20	Pavlovich RI, Vazquez-Vela G, Pardinas JL, Bustos Villarreal JM, Rico EC, de la Mora Behar G, 2002 Jul-Aug. "Basic science in digital imaging: digital dynamic radiography, multimedia, and their potential uses for orthopaedics and arthroscopic surgery." Arthroscopy 18 (6): 639-47 [PubMed] Abstract: In this article, we discuss the different types of up-to-date tools available to understand multimedia and its applications, imaging manipulation, digital video, and new approaches to surgical planning, digital dynamic radiography, and patient education aided by digital technology.
21	Biermann JS, Golladay GJ, Clough JF, Schelkun SR, Alexander AH, 2007. "Orthopaedic information: how to find it fast on the Internet." Instr Course Lect 56: 483-9 [PubMed] Abstract: The Internet is a rapidly expanding source of information that has gained a valued place in the knowledge armamentarium of the orthopaedic surgeon. Access to current knowledge, published literature, and a vast array of academic, federal, and commercial information has changed the information landscape for both orthopaedic surgeons and their patients. It is valuable to highlight readily available information for orthopaedic surgeons to use for continuing medical education, literature updates, patient education materials, and presentations. There are multiple techniques for accessing and organizing orthopaedic information as well as for identifying and using specific, high-quality, frequently updated Internet sources of information.
22	Gomoll AH, Thornhill TS, 2004. "Image catalogs." Clin Orthop Relat Res (421): 29-34 [PubMed] Abstract: The advent of digital photography and radiography allows documentation of interesting clinical findings with unprecedented ease, and many orthopaedic surgeons have taken extensive advantage of this opportunity to create large digital libraries of clinical results. However, this leaves surgeons with a rapidly increasing volume of data to store and organize; therefore, a system for archiving, locating, and managing images, radiographs, and digital slide presentations has become a crucial need in most orthopaedic groups and practices. However, many surgical groups and practices are not familiar with the computer technology available to initiate such systems. In this review, we discuss several software solutions currently on the market to address the specific needs of orthopaedic surgeons, and as a practical example, discuss a system that is in place in the Department of Orthopaedic Surgery at our institution. Overall, depending on the individual circumstances of each institution, there are various options that meet different technologic and financial requirements.
23	COA Bulletin 2001 #54 23-25 Digital Imaging Don Johnson
24	LaPorte RE, Linkov F, Villasenor T, Sauer F, Gamboa C, Lovalekar M, Shubnikov E, Sekikawa A, Sa ER, 2002. "Papyrus to PowerPoint (P 2 P): metamorphosis of scientific communication." BMJ 325 (7378): 1478-81 [PubMed]
25	Russell JA, Fincher AL, Woods GW, 1997. "The use of computer technology to improve the effectiveness of orthopaedic presentations." Instr Course Lect 46: 595-610 [PubMed]
26	Powerpoint - Focus your audience (2007) Clough JFM [Hands-on Workshop] [Website] Available at http://www.orthogate.org/workshops/powerpoint/powerpoint-focus-your-audience.html
27	Orthogate Workshops in Electronic Skills 2008 [Website] Available at http://www.orthogate.org/workshops/