Journal of Medical Systems, Vol. 16, Nos. 2/3, 1992
US HealthLink: A National Information Resource for Health Care Professionals William A. Yasnoff
US HealthLink is a new; comprehensive online medical information system designed specifically for health care professionals. Available to individuals for a fixed fee, it includes literature, news, diagnostic decision support, drug interactions, electronic mail, and bulletin boards. It also provides user-specific current awareness via clipping service, and fax delivery of both clipping and electronic mail information. US HealthLink can now be utilized to access a wide variety of medical information sources inexpensively.
INTRODUCTION The information explosion in medicine has nearly eliminated the possibility that a single individual can achieve and maintain mastery over even a fraction of available medical knowledge without assistance, despite increasing specialization and subspecialization. For many years, computers have been expected to improve this situation by providing ready access to a wide variety of available databases, responding rapidly to patient- and/or subject-specific queries with relevant and timely medical information. Cost and complexity have been major obstacles in achieving these objectives. Traditional online services with per-minute pricing have, to a large extent, been too expensive and/or too complex for use by most physicians. In addition, the cost of the computer equipment needed to access these services has also, until recently, been an obstacle to physician access. Few services have been oriented specifically to health care, so that access to a wide variety of databases was only possible by subscribing to and mastering the interfaces of multiple services. As a result, the vast majority of health care professionals do not directly utilize online services to help meet their information needs. US HealthLink was established to address these problems by offering access to a low cost, easy to use, comprehensive collection of medical information resources for a fixed monthly fee. It includes literature, diagnostic decision support, drug interactions, news, and therapeutic assistance products as well as From the Biomedical Information Communication Center, Oregon Health Sciences University, 3i81 SW Sam Jackson Park Road, Portland, Oregon 97201; and US HealthLink, IEI Network, Inc., One Wheaton Center, Suite 1611, Wheaton, Illinois 60187. 95 0148-5598/92/0600-0095506.50/0 © 1992 Plenum Publishing Corporation
96
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electronic mail and bulletin boards. A cooperative venture of the Biomedical Information Communication Center at Oregon Health Sciences University and IEI Network, Inc., a private firm formed specifically to operate US HealthLink, the service became available in late January 1992.
EVOLUTION US HealthLink evolved from AMA/Net,* the nationwide electronic medical information network developed and sponsored by the American Medical Association. Started in 1982, AMA/Net eventually attracted over 41,000 (mostly physician) subscribers, but was discontinued in August 1990 because of continuing operating losses. Meanwhile, the Biomedical Information Communication Center at OHSU had established a statewide network known as ORHION (ORegon Health Information ONline) and was looking for a mechanism to expand the available services while simultaneously moving the network toward financial self-sufficiency. Recognizing that most of the costs for operating a network are fixed, OHSU agreed to establish the new network using its computer facilities based on the software utilized to operate AMA/Net. By making the network available nationwide, the fixed costs could be distributed widely, reducing costs for all users. Since it would not be appropriate for OHSU as an institution to market a service nationwide, US HealthLink was organized as a cooperative venture with a private corporation.
PHILOSOPHY
US HealthLink embodies a specific philosophy toward access to information services by health care professionals. Comprehensive Information Services. A key objective of US HealthLink is to provide access to a wide variety of available electronic medical information sources. The service is organized to facilitate the addition of new services locally or via communications gateways. Low Cost, Fixed Pricing. US HealthLink is designed and organized to provide services at the lowest possible cost. By carefully selecting hardware, software, and communications resources, optimal use of personnel, and the cooperation of multiple information providers, subscribers can benefit from information that is both useful and affordable. By eliminating per-minute charges, the anxiety of the "meter" running is eliminated and costs are predictable. Ease of Use. The goal is for US HealthLink to be self-explanatory. No training should be necessary to use the service and there is no manual. However, extensive context-sensitive on line help is available throughout the system to guide users. Often, several user selectable interfaces are provided for the same information product. These vary from the simple, but inflexible interface for the novice, to a more complex set of commands available to the more experienced users. Inforraation Engineering. US HealthLink strives to organize and "engineer" * AMA Trademark. US HealthLinkis not affiliatedwith the AmericanMedicalAssociation.
US HealthLink
97
information so it is readily accessible. Providing information sorted, selected, and arranged to meet the individual needs of the user is the essential value of a computer-based service.
SERVICES
Online information systems are difficult to describe in print, and are best evaluated and understood via a demonstration. US HealthLink provides a toll-free number for this purpose (1-800-225-4652). While the services are described below, readers are encouraged to view the demonstration using a computer and modem to gain a more in-depth understanding of the available capabilities. Literature
EMPIRES. EMPIRES (Excerpta Medica Physician Information Reference and Education Service) consists of approximately 300,000 bibliographic citations from 320 key English language clinical journals. Designed specifically to address patient care queries, it provides rapid access to the recent clinical literature. Stored data includes title, author, source, index terms, date, and abstract (when available). All fields are indexed for rapid retrieval. Two interfaces are available: Easy Search allows access via one or two search terms, and selection of a date range for retrieval that defaults to the most recent 6 months. If more than 50 articles are retrieved, an optional third term may be entered to further narrow the search. All fields are searched and the display is in a fixed format. Advanced Search allows queries on specific fields as well as Boolean operations on the resultant retrieval sets. Fields to be displayed can be selected as desired. Both interfaces incorporate relevance ranking, which is a useful alternative to presenting citations in reverse chronologic order. The relevance ranking feature orders the citations according to the number of search term occurrences found in each one. This tends to place the more "relevant" articles at the top of the list, and allows even large retrieval sets (e.g., over 1000 documents) to be potentially useful. In Easy Search, relevance ranking is always used; in Advanced Search, it is only applied if specifically requested by the user. EMPIRES is updated weekly and is connected to the clipping service (see later). Since the lag time from publication to release in EMPIRES of new articles is only about five weeks, it represents the most current literature available on US HealthLink. MEDLINE. A 5-year, 1300 journal subset of Medline consisting of approximately 1,000,000 citations is also available. The same Easy and Advanced Search interfaces used for EMPIRES also are used to access Medline. The journals were selected to correspond to the collection of the OHSU library. This database will be expanding in the future both in terms of journals covered and access to citations prior to 1987. News
US HealthLink provides news items from several wire services (including UPI). News is updated 24 hrs/day, 7 days/week, as soon as it is available. Medical, computer and electronics, and environmental stories are sorted into nineteen categories; a reverse
98
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chronologic listing is also available. It is possible to search news items for a specific term, and the news is connected to the clipping service (see later).
DXplain Diagnostic Decision Support DXplain is a diagnostic decision support system developed at the Laboratory of Computer Science of Massachusetts General Hospital. It is a sophisticated database of signs, symptoms, laboratory findings, and their relationships to over 2000 disease entities. DXplain accepts a set of findings and generates a list of possible diagnoses that could explain those findings. The list is presented in ranked order with the common conditions segregated from the rare and the very rare ones. The real power of DXplain is in its ability to inform the user about each potential disease or condition; on request, DXplain produces a list of those terms entered that support the given disease, those that would not support it, and, most importantly, those findings that were not reported but would be expected in a patient with that particular disease. This "explain" capability, from which the product derives its name, makes it a powerful thinking and educational tool in the diagnostic process. DXplain also has a question mode where it will attempt to elicit relevant additional findings to clarify the list of possible diagnoses. In addition, a brief synopsis is available for each of the disease conditions providing signs, symptoms and other relevant information including key references. While DXplain is typically used to evaluate findings in a specific case, it may also be used as a disease reference tool or to provide information about the range of conditions associated with a particular finding. The use of DXplain is restricted to licensed physicians and medical educational institutions.
MEDICOM Drug Interactions The MEDICOM drug interactions package, provided by Professional Drug Systems (St. Louis, Missouri), produces a list of interactions for an entire medication profile as well as allergies and diseases for a particular patient. Each of the interactions has an associated significance level; it is possible to eliminate the display of interactions at lower levels of clinical significance. The latter feature can be a significant time saver in avoiding review of minor interactions that are of little clinical consequence. It is also possible to store a profile for a given patient, using a coded name designation. The profile can then be retrieved on a subsequent occasion, avoiding the need to reenter the medication profile for a complex case.
Coagulation Advisor Coagulation Advisor, developed at Yale University, allows rapid access to expert information about coagulation disorders. It is one of a series of "advisor" programs that provide the ability to select relevant expert comments from a large database of clinical information regarding the management of specific conditions. This selection process is based on clinical criteria entered by the user. It is helpful to think of the advisor programs as "interactive papers" which are selectively referenced according to specific criteria of a given case. This can be a signif-
US HealthLink
99
icant time saver since it is difficult and tedious to extract information from a long monograph relevant to a specific patient. The advisor programs also provide an excellent vehicle for the delivery of practice parameters. Such parameters often are in a form that is so long and complex that they are difficult to apply in specific clinical situations. Using the rule-based advisor paradigm, the relevant parameter guidelines for a specific case can rapidly be abstracted and presented to the clinician. It is hoped that making practice parameters and guidelines easier to use in this manner will increase both their acceptance and use in clinical medicine.
C l i p p i n g Service The US HealthLink clipping service provides a mechanism for monitoring literature and news on a subject chosen by the user. A clipping folder is established with one or more terms describing the interest of the user, and the folder is designated as applying to either or both of the literature databases and/or the medical news database. Each time the literature is updated (currently once per week), any new articles on the subject of interest are automatically placed in the clipping folder. For news, all the news of the previous day is scanned in the early morning hours, and relevant stories are also posted to the clipping folder. Using the clipping mechanism, it is easy for clinicians to maintain their current awareness on topics of interest. One clipping folder is included with every US HealthLink subscription; additional folders are available for a small additional fee. Additional services will be added to clipping in the near future to make it an even more comprehensive current awareness service.
F a x A l e r t sM The FaxAlert service adds another dimension to access to information by providing weekly fax delivery of notifications about electronic mail, bulletin board postings, and clipping folder contents. The FaxAlert service provides the ability for the clinician to be informed about new items on US HealthLink without having to connect to the network.
Electronic C o m m u n i c a t i o n US HealthLink provides both electronic mail and bulletin boards for electronic communications. The electronic mail system was specifically designed for ease of use by health care professionals. Several interface options are available, from menu driven for novice users, to command driven for experts. Electronic mail may optionally be delivered as a fax to one or more fax destinations. This provides an excellent mechanism for "forced delivery" of urgent information to a group of people that is not dependent on the recipients either being subscribers to US HealthLink or even having a computer system. The bulletin board system provides for public read-and-write bulletin boards, readonly bulletin boards for announcements, and totally private bulletin boards that are only visible to the authorized users. Each subscriber can determine which boards to track; tracking a bulletin board results in automatic notification of all new postings on
100
Yasnoff
log in or via FaxAlert. This provides a convenient mechanism for monitoring communications on specific topics.
DISTRIBUTION OF ADDITIONAL SERVICES US HealthLink is designed to easily accommodate additional information services. One important goal of the system is to be a vehicle for the dissemination of both databases and medical informatics applications. Many important medical computing systems are not accessible beyond the originating institution. The cost and complexity of distributing such systems often has been an obstacle in their widespread use. By providing a mechanism for distribution of such services, it is hoped that developers of key applications can more easily make them available to other interested health care professionals. While the online distribution mechanism is clearly not appropriate for all such systems, it does have the important advantage that updates are performed centrally and distributed immediately so everyone is utilizing the most recent information or the most recent version of the particular product.
CONCLUSION US HealthLink is a comprehensive, low cost, fixed fee medical information service designed for health care professionals. By providing easy access to multiple sources of medical data, US HealthLink can assist health care professionals in meeting their increasingly complex information needs.
US HealthLink: A National Information Resource for Health Care Professionals William A. Yasnoff
US HealthLink is a new; comprehensive online medical information system designed specifically for health care professionals. Available to individuals for a fixed fee, it includes literature, news, diagnostic decision support, drug interactions, electronic mail, and bulletin boards. It also provides user-specific current awareness via clipping service, and fax delivery of both clipping and electronic mail information. US HealthLink can now be utilized to access a wide variety of medical information sources inexpensively.
INTRODUCTION The information explosion in medicine has nearly eliminated the possibility that a single individual can achieve and maintain mastery over even a fraction of available medical knowledge without assistance, despite increasing specialization and subspecialization. For many years, computers have been expected to improve this situation by providing ready access to a wide variety of available databases, responding rapidly to patient- and/or subject-specific queries with relevant and timely medical information. Cost and complexity have been major obstacles in achieving these objectives. Traditional online services with per-minute pricing have, to a large extent, been too expensive and/or too complex for use by most physicians. In addition, the cost of the computer equipment needed to access these services has also, until recently, been an obstacle to physician access. Few services have been oriented specifically to health care, so that access to a wide variety of databases was only possible by subscribing to and mastering the interfaces of multiple services. As a result, the vast majority of health care professionals do not directly utilize online services to help meet their information needs. US HealthLink was established to address these problems by offering access to a low cost, easy to use, comprehensive collection of medical information resources for a fixed monthly fee. It includes literature, diagnostic decision support, drug interactions, news, and therapeutic assistance products as well as From the Biomedical Information Communication Center, Oregon Health Sciences University, 3i81 SW Sam Jackson Park Road, Portland, Oregon 97201; and US HealthLink, IEI Network, Inc., One Wheaton Center, Suite 1611, Wheaton, Illinois 60187. 95 0148-5598/92/0600-0095506.50/0 © 1992 Plenum Publishing Corporation
96
Yasnoff
electronic mail and bulletin boards. A cooperative venture of the Biomedical Information Communication Center at Oregon Health Sciences University and IEI Network, Inc., a private firm formed specifically to operate US HealthLink, the service became available in late January 1992.
EVOLUTION US HealthLink evolved from AMA/Net,* the nationwide electronic medical information network developed and sponsored by the American Medical Association. Started in 1982, AMA/Net eventually attracted over 41,000 (mostly physician) subscribers, but was discontinued in August 1990 because of continuing operating losses. Meanwhile, the Biomedical Information Communication Center at OHSU had established a statewide network known as ORHION (ORegon Health Information ONline) and was looking for a mechanism to expand the available services while simultaneously moving the network toward financial self-sufficiency. Recognizing that most of the costs for operating a network are fixed, OHSU agreed to establish the new network using its computer facilities based on the software utilized to operate AMA/Net. By making the network available nationwide, the fixed costs could be distributed widely, reducing costs for all users. Since it would not be appropriate for OHSU as an institution to market a service nationwide, US HealthLink was organized as a cooperative venture with a private corporation.
PHILOSOPHY
US HealthLink embodies a specific philosophy toward access to information services by health care professionals. Comprehensive Information Services. A key objective of US HealthLink is to provide access to a wide variety of available electronic medical information sources. The service is organized to facilitate the addition of new services locally or via communications gateways. Low Cost, Fixed Pricing. US HealthLink is designed and organized to provide services at the lowest possible cost. By carefully selecting hardware, software, and communications resources, optimal use of personnel, and the cooperation of multiple information providers, subscribers can benefit from information that is both useful and affordable. By eliminating per-minute charges, the anxiety of the "meter" running is eliminated and costs are predictable. Ease of Use. The goal is for US HealthLink to be self-explanatory. No training should be necessary to use the service and there is no manual. However, extensive context-sensitive on line help is available throughout the system to guide users. Often, several user selectable interfaces are provided for the same information product. These vary from the simple, but inflexible interface for the novice, to a more complex set of commands available to the more experienced users. Inforraation Engineering. US HealthLink strives to organize and "engineer" * AMA Trademark. US HealthLinkis not affiliatedwith the AmericanMedicalAssociation.
US HealthLink
97
information so it is readily accessible. Providing information sorted, selected, and arranged to meet the individual needs of the user is the essential value of a computer-based service.
SERVICES
Online information systems are difficult to describe in print, and are best evaluated and understood via a demonstration. US HealthLink provides a toll-free number for this purpose (1-800-225-4652). While the services are described below, readers are encouraged to view the demonstration using a computer and modem to gain a more in-depth understanding of the available capabilities. Literature
EMPIRES. EMPIRES (Excerpta Medica Physician Information Reference and Education Service) consists of approximately 300,000 bibliographic citations from 320 key English language clinical journals. Designed specifically to address patient care queries, it provides rapid access to the recent clinical literature. Stored data includes title, author, source, index terms, date, and abstract (when available). All fields are indexed for rapid retrieval. Two interfaces are available: Easy Search allows access via one or two search terms, and selection of a date range for retrieval that defaults to the most recent 6 months. If more than 50 articles are retrieved, an optional third term may be entered to further narrow the search. All fields are searched and the display is in a fixed format. Advanced Search allows queries on specific fields as well as Boolean operations on the resultant retrieval sets. Fields to be displayed can be selected as desired. Both interfaces incorporate relevance ranking, which is a useful alternative to presenting citations in reverse chronologic order. The relevance ranking feature orders the citations according to the number of search term occurrences found in each one. This tends to place the more "relevant" articles at the top of the list, and allows even large retrieval sets (e.g., over 1000 documents) to be potentially useful. In Easy Search, relevance ranking is always used; in Advanced Search, it is only applied if specifically requested by the user. EMPIRES is updated weekly and is connected to the clipping service (see later). Since the lag time from publication to release in EMPIRES of new articles is only about five weeks, it represents the most current literature available on US HealthLink. MEDLINE. A 5-year, 1300 journal subset of Medline consisting of approximately 1,000,000 citations is also available. The same Easy and Advanced Search interfaces used for EMPIRES also are used to access Medline. The journals were selected to correspond to the collection of the OHSU library. This database will be expanding in the future both in terms of journals covered and access to citations prior to 1987. News
US HealthLink provides news items from several wire services (including UPI). News is updated 24 hrs/day, 7 days/week, as soon as it is available. Medical, computer and electronics, and environmental stories are sorted into nineteen categories; a reverse
98
Yasnoff
chronologic listing is also available. It is possible to search news items for a specific term, and the news is connected to the clipping service (see later).
DXplain Diagnostic Decision Support DXplain is a diagnostic decision support system developed at the Laboratory of Computer Science of Massachusetts General Hospital. It is a sophisticated database of signs, symptoms, laboratory findings, and their relationships to over 2000 disease entities. DXplain accepts a set of findings and generates a list of possible diagnoses that could explain those findings. The list is presented in ranked order with the common conditions segregated from the rare and the very rare ones. The real power of DXplain is in its ability to inform the user about each potential disease or condition; on request, DXplain produces a list of those terms entered that support the given disease, those that would not support it, and, most importantly, those findings that were not reported but would be expected in a patient with that particular disease. This "explain" capability, from which the product derives its name, makes it a powerful thinking and educational tool in the diagnostic process. DXplain also has a question mode where it will attempt to elicit relevant additional findings to clarify the list of possible diagnoses. In addition, a brief synopsis is available for each of the disease conditions providing signs, symptoms and other relevant information including key references. While DXplain is typically used to evaluate findings in a specific case, it may also be used as a disease reference tool or to provide information about the range of conditions associated with a particular finding. The use of DXplain is restricted to licensed physicians and medical educational institutions.
MEDICOM Drug Interactions The MEDICOM drug interactions package, provided by Professional Drug Systems (St. Louis, Missouri), produces a list of interactions for an entire medication profile as well as allergies and diseases for a particular patient. Each of the interactions has an associated significance level; it is possible to eliminate the display of interactions at lower levels of clinical significance. The latter feature can be a significant time saver in avoiding review of minor interactions that are of little clinical consequence. It is also possible to store a profile for a given patient, using a coded name designation. The profile can then be retrieved on a subsequent occasion, avoiding the need to reenter the medication profile for a complex case.
Coagulation Advisor Coagulation Advisor, developed at Yale University, allows rapid access to expert information about coagulation disorders. It is one of a series of "advisor" programs that provide the ability to select relevant expert comments from a large database of clinical information regarding the management of specific conditions. This selection process is based on clinical criteria entered by the user. It is helpful to think of the advisor programs as "interactive papers" which are selectively referenced according to specific criteria of a given case. This can be a signif-
US HealthLink
99
icant time saver since it is difficult and tedious to extract information from a long monograph relevant to a specific patient. The advisor programs also provide an excellent vehicle for the delivery of practice parameters. Such parameters often are in a form that is so long and complex that they are difficult to apply in specific clinical situations. Using the rule-based advisor paradigm, the relevant parameter guidelines for a specific case can rapidly be abstracted and presented to the clinician. It is hoped that making practice parameters and guidelines easier to use in this manner will increase both their acceptance and use in clinical medicine.
C l i p p i n g Service The US HealthLink clipping service provides a mechanism for monitoring literature and news on a subject chosen by the user. A clipping folder is established with one or more terms describing the interest of the user, and the folder is designated as applying to either or both of the literature databases and/or the medical news database. Each time the literature is updated (currently once per week), any new articles on the subject of interest are automatically placed in the clipping folder. For news, all the news of the previous day is scanned in the early morning hours, and relevant stories are also posted to the clipping folder. Using the clipping mechanism, it is easy for clinicians to maintain their current awareness on topics of interest. One clipping folder is included with every US HealthLink subscription; additional folders are available for a small additional fee. Additional services will be added to clipping in the near future to make it an even more comprehensive current awareness service.
F a x A l e r t sM The FaxAlert service adds another dimension to access to information by providing weekly fax delivery of notifications about electronic mail, bulletin board postings, and clipping folder contents. The FaxAlert service provides the ability for the clinician to be informed about new items on US HealthLink without having to connect to the network.
Electronic C o m m u n i c a t i o n US HealthLink provides both electronic mail and bulletin boards for electronic communications. The electronic mail system was specifically designed for ease of use by health care professionals. Several interface options are available, from menu driven for novice users, to command driven for experts. Electronic mail may optionally be delivered as a fax to one or more fax destinations. This provides an excellent mechanism for "forced delivery" of urgent information to a group of people that is not dependent on the recipients either being subscribers to US HealthLink or even having a computer system. The bulletin board system provides for public read-and-write bulletin boards, readonly bulletin boards for announcements, and totally private bulletin boards that are only visible to the authorized users. Each subscriber can determine which boards to track; tracking a bulletin board results in automatic notification of all new postings on
100
Yasnoff
log in or via FaxAlert. This provides a convenient mechanism for monitoring communications on specific topics.
DISTRIBUTION OF ADDITIONAL SERVICES US HealthLink is designed to easily accommodate additional information services. One important goal of the system is to be a vehicle for the dissemination of both databases and medical informatics applications. Many important medical computing systems are not accessible beyond the originating institution. The cost and complexity of distributing such systems often has been an obstacle in their widespread use. By providing a mechanism for distribution of such services, it is hoped that developers of key applications can more easily make them available to other interested health care professionals. While the online distribution mechanism is clearly not appropriate for all such systems, it does have the important advantage that updates are performed centrally and distributed immediately so everyone is utilizing the most recent information or the most recent version of the particular product.
CONCLUSION US HealthLink is a comprehensive, low cost, fixed fee medical information service designed for health care professionals. By providing easy access to multiple sources of medical data, US HealthLink can assist health care professionals in meeting their increasingly complex information needs.
