Online Medical Services
Companion NetView:
Online medical services: the second generation
by Marjorie Lazoff, MD
Emergency Medicine
Philadelphia, Pennsylvania
Medical Editor
Medical Computing Today

accepted for publication in Medical Computing Today January 1999
(updated) February 1999
Originally published in the December 1998 issue of Medical Software Reviews

Selection Criteria - Ratings & Limitations
SERVICES: MD Consult - PHP - Reutershealth - HealthGate - POL - Medscape - Other
FEATURES: Search Engines - Textbooks - Journals - Original Content
Online CME - Medical News - Communications

Medline and other freely distributed medical references arguably diminish the need for online services that charge a fee, flash banners, or require personal and professional information as part of registration. But their "service" goes beyond access to a particular database: with varying degrees of success, they assemble pertinent and high quality references; present them in a straightforward manner using appropriate navigational tools; and insure that all information is well-maintained, that all original content is accurate, and that the online environment is conducive to consultation, study, and communication. Six popular fee-based and free online medical services -- HealthGate, MDConsult, Medscape, Physicians' Home Page, Physicians' Online, and Reutershealth -- profess to offer convenient, easily accessible professional information. How does their content compare with each other and feature-by-feature within different categories of professional information, and from the broader perspective of the Web itself? As an aggregate these sophisticated megasites house some of the best information on the Web, although strengths vary among the individual services. And, just as important, equally or more impressive resources reside on independent Web sites.

Sections Selection Criteria

I sought to identify the most popular, strongest, or most innovative services providing online clinical and/or educational resources to medical professionals. Priority was given to reviewing fee-based services. Among these, large database services such as Ovid and ScienceDirect were excluded since they market themselves almost exclusively to institutions, and their casual use is prohibitively expensive. All identified services are available through the Web.

Interestingly, the distinction between free and fee-based resources was less than expected. For example, both Physician's Home Page (PHP) and HealthGate include free content within their fee-based services, and vice versa. And Physicians' Online (POL) offers Reuters' subscription-based Medical News free of charge, albeit without a search engine or extensive archives.

Another surprise: differences in content or presentation between fee-based services and those of the two largest free medical service sites -- POL and Medscape -- could not be accounted for by user fees, sponsorships, advertising, or marketing budgets. Presentation and content depend less on the source of support than the hard work, talent, and attention of the physicians, administrators, and companies running the site. Therefore, reviews of free sites are included as well. As long as content is independent of support, it's an individual preference whether a particular site is more offensive to the wallet or the visual cortex.

CME access or cost was not a factor in selection, as policies vary widely from site to site and sometimes even within a site. It turns out that five of the six services boast good-to-excellent CME resources.

Sections Ratings & Limitations

More than with most comparative reviews, what constitutes the best online medicial service depends on individual and group needs and subjective preferences. Also, these megasites are constantly evolving, adding new features, and making fee-based features freely available. Finally, Internet access is not commented on, since the connection and time of day are overriding factors.



Sections MD Consult
last visited November 1998

The present version of MD Consult was introduced just over a year ago by founding publisher-partners Lippincott Williams & Wilkins, W.B. Saunders, and Mosby-Year Book. Describing its service as "the ultimate clinical library," MD Consult emphasizes scholarly material -- a group of authoritative textbooks and full-text professional periodicals -- together with news and other time-sensitive reviews, summaries, and features, many specific to the service. These latter resources commonly include links to other MD Consult references, adding depth to straightforward reviews and turning otherwise lightweight articles into effective, pleasant learning tools.

MD Consult is designed for and primarily used by practicing physicians and trainees, but users will encounter no physician on the site, other than the rare author of an original journal review.

The home page divides content into two groups: Answers, with its medical and clinical resources and interactivity, and Update: STAT, with its daily news and other non-scholarly articles and references. The home page also includes a utilities toolbar and direct links to individual articles, somewhat customized to the user's specialty interests. Novel icons and design are visually pleasing, but more than offset by erratic navigation and multiframes formatting. "MDC only" notations, which brag that MD Consult is more current than Medline, also prove that links are not well maintained when they remain six months after Medline updating. Confused naming is endemic; for example, messages or posts in the discussion groups are referred to as "articles," the menu icon is sometimes labeled "story list," and titles such as STAT and Personal Home Page are misapplied. The print feature does not include advanced formatting such as PDF. The site functions, but it's a shame the content and features are not better presented.

Not surprisingly, MD Consult's most popular feature is its collection of 37 authoritative reference textbooks. Books can be accessed individually using the expanding/contracting table of contents or indexes, or searched as a group (not selectively) via a keyword search engine. Doing so brings up a list of books in descending order of number of hits; select a book, and see alphabetical links to hits in a left-hand column; click a link to access the page(s) on the right. Once the text is displayed, the left frame can be compressed. The text database is a potpourri of classics÷Cecil (medicine), Nelson (pediatrics), Sabiston (surgery), Rosen (EM), Bone (pulmonary and critical care medicine), Braunwald (cardiology), DeVita (oncology)÷among dozens of major subspecialty texts and handbooks. In addition to medical students, residents and practicing physicians who consult basic textbooks for clinical or research purposes, this resource should be useful to those seeking core content for board certification or recertification. Thumbnail graphics enlarge to good quality but are painfully slow to load, there are no personalization features such as highlighting and notes, and there is no free text search engine to identify the thousands of important words and phrases that never make it into a book's index or keyword list.

Users can also search journals, practice guidelines, patient education handouts, and STAT/news. For example, click on "search page," then "journal literature," and the same keyword is available for searching Medline, Aidsline, Healthstar, and Cancerlit databases (for articles outside MD Consult's references, an automatic document delivery system is provided at an additional fee); 24 medical journals (although not the top five, it does include excellent ones such as Pediatrics and Neurology); 23 Saunders Clinics of North America; and 29 Mosby Yearbooks. Unlike textbooks, no periodical or issue can be accessed directly, so MD Consult's search engine is especially important to the journal database. Staff is working to improve the engine, which has relatively few limits on searching parameters, almost no control over output, and default settings that fail to prioritize journals.

Other Answers features include 500 clinical practice guidelines; the 1998 edition of Mosby's GenRx; more than 2,500 patient education handouts, some available in Spanish; and full access by issue (no search engine) to 14 of American Health Consultants' clinically oriented monthly newsletters for self-education or CME, with links to other MD Consult references. Pedestrian discussion groups feature non-intuitive posting practices and poorly attended threads.

In the Update: STAT portion of the site, Reuters' daily medical news feed is given a specialty-specific interface, with a variety of date options and links to MD Consult references; see Medical News for more about this excellent feature. This Week's Journals posts timely summaries of lead clinical articles from the major medical and assorted other journals, as written by Reuters and MD Consult staff.

What Patients are Reading is more casual and reflective, relating stories from major broadcast, newspapers, and magazines, with links to database reference and journal articles. The evolving series summary, "Last Night on ER," for example, illustrates the creative thinking evident in this section. Narratives appropriately concentrate on medical content, providing enough details so that, along with the scholarly article links, users can theoretically learn from a TV show that deservedly prides itself on factually correct medical stories. Unfortunately, the medically unsophisticated writing is the dealbreaker; October 22nd and 29th summaries each contained obvious errors that are still not fully corrected on line, and the recent summary included phrases such as, "(a) normal Babinsky [sic] reflex," "(t)he tests revealed an obstruction in a 'step ladder' pattern," "(t)he man had supraventricular tachycardia (we assume causing atrial fibrillation)," and an incorrect description of the duties of an interim Department Chief.

Thursday is Clinical Topic Tour day, on which a new health-related topic such as breast cancer prevention or emergency contraception is briefly summarized and linked to dozens of journal articles, books, practice guidelines, patient education, drug information, and Web resources. Narrowly focused Tours are relatively successful as superficial reviews, but in general there are too many clinical holes and biases to trust this feature. For example, the Stroke tour missed classic NEJM and Lancet articles and editorials, among others; there's no overt mention why the Smoking Cessation tour focuses almost exclusively on nicotine patches (I was told the tour was inspired by the article mentioned in the fourth paragraph, which isn't even referenced or linked); "the Calcium Channel Blocker controversy" fails to explain exactly what the controversy is; and hypericum (St. John's wort) is the only treatment mentioned in the narrative for depression.

To correct a self-promotional aside from ER's October 29th summary, if Dr. Carter had MD Consult on his laptop he wouldn't have to lug around 37 textbooks÷but he'd still have to go to the library for most full text journal articles. MD Consult is an exciting work-in-progress that many students and physicians may justifiably want today, but it's not "the ultimate clinical library" (yet).

Sections Physician's Home Page
last visited November 1998

Physicians' Home Page (PHP)'s mission is "to harness the best Internet and online technology." It is owned by SilverPlatter, an established vendor of CD-based medical education and database products that markets its software on several interrelated, CD-affiliated sites. In particular, Primary is a free biweekly Web site associated with SilverPlatter's Core Curriculum Committee in Primary Care CD-ROM Series. On Primary, a multimedia CME Virtual Symposia and selected MD Opinion -- two PHP features÷are available gratis alongside Primary's original content. It's an incestuous relationship among all these Silver Platter Web resources. But that doesn't diminish Silver Platter's generosity and not everything is veiled marketing; NetView readers may be familiar with SilverPlatter's relatively well-maintained WebMedLit, a free Web page with links and group searches to the most current issues of 23 medical journals.

Free annual subscriptions to PHP are offered to purchasers of selected SilverPlatter software and to all physicians who practice a primary care specialty. This is not listed on PHP's subscription information; see About Primary -- PHP.

PHP's home page is less busy but more ornate than its competitors. Unfortunately, the site uses a number of different interfaces, which works against a unified service. On the other hand, navigation is easy and intuitive, and their text-only pages allow for relatively quick loading. The toolbar divides content into Search, Publications (original content), Library (Web links), and CME. Content is exclusively clinical, and written by well-credentialed physicians and physician-editors.

The service's main attraction, according to staff, is its powerful search engine for Medline, Aidsline, HealthStar, and BioethicsLine Plus; see Search Engines for more information and a comparison of online search engines. A free preview accessible from PHP's home page introduces its features and interface using Medline 1990-1991 as a sample database.

The search engine also provides access to Drug Information Handbook, PHP's only drug reference and the same Lexi-Comp handbook available on MedGate (see below). As compared to MedGate, however, PHP's version is accessible only by keyword and free text searches, has a less elegant interface, is without phonetic pronunciations, and contains some errors, such as Allegra mislinked to Zyrtec, and no listing for fexofenadine (generic Allegra).

Perhaps the strongest PHP feature is Virtual Symposia, SilverPlatter's multimedia CME lectures. Shockware, a free browser plug-in for multimedia, allows easy and relatively bug-free access to the lectures' audio, clinical images, slides, and text. Topics are diverse and clinically relevant, practical, and well referenced. Each concludes with a group of interactive multiple-choice questions which members can answer, then submit the perfect grade for free CME credit. Content is associated with the Core Curriculum Committee, and new lectures are premiered gratis for two weeks on the Committee's online site, Primary.

PHP's original content, MD Digests and MD Opinion, is physician-authored and edited. MD Digests is freely available from the home page, but only subscribers can access post-article links. Twice a week, a question is posed based on an article from among the top five medical journals, and then answered with a succinct clinical summary of the article along with links to Medline using prepared searches, and Web resources.

The writeups are solid, but the Best Search links are sometimes not. For example, Sept 17, 1998's "What Is the Best Treatment for Status Epilepticus?" links to management of intractable seizure disorders, treatment for post-traumatic seizures, and migraine and epilepsy÷none of which has anything to do with status epilepticus. The list of Web links that follows has only one link germane to the topic. Oct. 15th's "Can Electrical Stimulation of the Brain Be Used as a Treatment for Parkinson's Disease?" and October 1st's "Do Folate Supplements Prevent Colon Cancer?" are more successful in this regard, although I wonder if anyone noticed that the full text of the summarized article is hidden under Practice Info links.

MD Opinion, the other Publication feature, is an FAQ list of controversies, difficulties, and new clinical information for primary physicians. Hundreds of questions are divided into medical specialties, with an editorial panel of physicians providing expert opinion alongside member submissions. Theoretically useable as a database, the keyword search feature is a nice touch. Unfortunately, the bulk of the Opinion is from 1996, opinions vary in quality depending on the expert, and large sections stand vacant. A similar Silver Platter site, First Look/Second Look (, has the same strengths and limitations.

The Library section is a well organized but dated Web listing of medically relevant documents and resources. The "Added This Week" feature is especially neglected; for example, one journal describes a free trial period that ended last March. Even the workable links usually date from 1996 and 1997. Worse, some of the links are not appropriate for physicians, as the author is not identified or its content is poor quality. The interface is problematic as well, with the main content crowded into a left-sided frame. It looks like hard work and great ideas were left to gather cobwebs.

PHP contains a solid search engine and excellent CME features -- both SilverPlatter strengths. Original content postings and e-mailings keep subscribers reading, and good project ideas abound. But most SilverPlatter sites are handicapped by poor interface design and half-completed, careless, or outdated Web work. Staff members insist they update daily and that links are rigorously maintained. I hope SilverPlatter takes a second look around.

Sections Reutershealth
last visited November 1998

Reutershealth describes itself as "the most comprehensive and timely medical news and information subscription service available on the Internet!" Its parent, Reuters Group PLC, already omnipresent on the Web as a consumer health news service, recently announced the acquisition of France's APM International, which promises to add international depth.

The home page is well organized and relatively attractive. Given the less intensive nature of its databases, this site can employ frames more successfully than sites with scholarly or clinical content. Unfortunately, a relatively high proportion of the site is devoted to marketing, and the default page after submitting changes to Update Personal Information returns to an older form with a far lower subscription fee. Adding a Medline search engine should not have doubled the price.

Health eLine is the collection of several dozen health articles on Reutershealth, and together with 30 to 40 medical headlines is available gratis off the site's home page. Subscribers enjoy unrestricted access to the full text medical stories grouped into 17 clinical and business medicine topics. Each story is several paragraphs in length, well written, and directed at a professional audience. The News Archive section is especially strong, with basic and advanced searches for six years' worth of over 25,000 health and medical stories. See Medical News for features on other services and elsewhere on the Web.

Medications mentioned in news articles are linked to a solid drug database, Gold Standard Multimedia's Clinical Pharmacology. Access to its content is also via a search engine, full monographs (alphabetized index of most drugs), or mini monographs (investigational drugs, combination therapy, less common drugs, nutraceuticals, and nutritional supplements). Full monographs include photo and text identification, dates of revisions, alphabetized list of interactions, and other thoughtful touches. Navigation within monographs, however, is clumsy at times.

Reutershealth should attract medical writers, health administrators, and others who require a reference database of new and archived health and medical news, alongside a drug reference book and convenient Medline access.

Sections HealthGate
last visited November 1998

HealthGate, a well-established Web enterprise, states its objective is "to make information access and coverage both thorough and easy." Its site is full of medical, nursing, mental health, and general public resources, the latter two now freely housed within Instream Psychlink and HealthGate's staff includes a highly credentialed physician advisor, but the medical areas contain no physician presence and there is no original medical content.

Among online physicians, HealthGate is best known for its user-friendly search engine accessing a generous selection of free NLM databases: Medline, Aidsline, HealthStar, Bioethicsline, Cancerlit, Aidstrial, and Aidsdrugs. HealthGate was also one of the first sites to employ advertising banners, a practice that today has all but overtaken the Web. But kudos to HealthGate (and Medscape) for banners that aren't visually assaulting, that do not paralyze navigation, and that appear only on the top and/or bottom of scrollable pages.

HealthGate's strength lies in its diversity of health databases and resources. New programming is slowly replacing the old frames format with a less oppressive, Java-scripted interface. Whether due to this improved interface or post-review familiarity, I no longer require an abacus to calculate HealthGate's various fee-based options. There are free and there are fee-based transactional databases, or users may sign up for a preset combination called an access plan. Like a Chinese restaurant, you can order an entree or two, but you hope that what you want comes as a combination plate with soup, fried rice, and an egg roll.

The MedGate Access Plan is HealthGate's combination plate designed to meet the needs of medical professionals. Best accessed by members though its own home page, MedGate eliminates the advertising on Medline and the other NLM databases (use the links on the page itself, not the side panel). The page also provides links within a frames format to two free Web resources: headlines from Newswire, a medical business-oriented news service, and the CDC's Morbidity and Mortality Weekly Reports. Unfortunately, MedGate offers no improvement to the Web's interface or content; bookmarking would do as much for users within or outside HeathGate. Although not available as a link on MedGate's home page, HealthGate provides free Web access to Diagnostic Procedures Handbook, a nice resource detailing radiologic and other diagnostic and therapeutic procedures.

Fee-based resources include daily medical news articles from Reuters; 1998 Drug Information Handbook with solid medication and pharmacology content÷and much better interface÷than the same reference on PHP, and the Detwiler Directory of Health and Medical Resources, filled with general information on health agencies and associations. Fee-based databases include MDX Health Digest database of articles from more than 200 consumer health publications and AARP's AgeLine comparable database on geriatrics; while valuable databases for other purposes, neither rivals Medline for routine clinical practice or research. Like NLM's databases, both access abstracts only, linking full-text articles to HealthGate's automatic delivery system for an additional fee.

MedGate may not be the best bundle for clinicians or house staff as opposed to, for example, social services or health administrators. But HealthGate itself offers nice freebies, a generous collection of NLM and transactional databases, and a growing number of allied health and public resources, all within an improving interface.

Sections Physician' Online
last visited February 1999

Founded in 1994 with the goal of "providing information quickly and conveniently to a physicians-only audience," Physicians' Online was the first online service to offer free Medline to registered physicians. Its communications, educational, and professional features have grown significantly since its fledging software days into the present Web site and bargain-priced Internet service provider (ISP). Physician involvement in content, Web links, and discussion groups insures a strong clinical and practical bent.

Present efforts at POL, as in the industry in general, seem directed at developing management features for physicians with independent or small group practices. A new software package, POL Office, hopes to recapture a proprietary audience by offering two free hours of non-POL Web access per month, and savvy users can rearrange the software's desktop to largely avoid banner ads. Create a Free Web Site debuted in October, and already includes thousands of physicians, most gathered within a patient-searchable Physician Web Site Directory.

POL's home page has been favorably revamped and now emphasizes its discussion groups, major medical databases, softer features and various announcements. Heavy corporate sponsorship has allowed POL to defray subscription fees, and drug companies often sponsor individual sections, including expert discussants on occasion. Banner ads have always graced the bottom of POL screens. Unfortunately their activity together with programming gaffes handicap navigation; for example, downloading a page is delayed while ads refresh, and there's no programmed exit out of the otherwise fine Clinical Pharmacology or Medi-Span references. The search page, already visually busy, includes a second banner that is small but quite distracting. Old names and features confuse this complex site, and one gets the sense some Leisure links have been forgotten by the newer POL Personal Shopper (nee Buyer's Guide).

Medical databases include Medline, Aidsline, Healthstar, and Cancerlit, with access to full-text articles via Uncover at an additional fee. POL's search engine allows for natural language or Boolean operators, and form-based (best for a specific article) or standard searches, but advanced features are lacking and citation retrieval is far from optimal. A link to PubMed is provided, as is a collection of quality Web drug resources. These links exemplify POL's practice of offering thoughtful, judicious access to top medical sites outside the service, albeit at the price of distracting banner ads. Note that the only access to Gold Standard Multimedia's Clinical Pharmacology is through a search engine; see fee-based Reutershealth for full access to this comprehensive resource.

Clinical resources, some with CME, are equally strong. A prime example is corporate-supported Controversies in Cardiology. The original content seems solid, and the newer sections are attractive although poor color contrast may affect palmtops and other users. The authors participate in an online group discussion for one to two months after each section is released. POL also offers Outlines in Clinical Medicine (OCM), whose contributors are mostly affiliated with Harvard institutions. OCM's 700-plus succinctly summarized topics are well referenced, frequently updated, and have surprising depth of information given its outline format, although familiarity with the topic is sometimes needed to understand the issues presented. A badly needed search engine is under construction.

POL links to about 100 medical journals, and although the list needs annotation and updating the resource is not abandoned; recommendations for inclusion are readily incorporated. Many full-text Web treasures are included, as is direct access to the table of contents of the current issue of the five major medical journals. Other clinical resources include a forgettable collection of Clinical Practice Guidelines.

Fun interactive features such as Clinical Quizzes and Issues in Clinical Management tally member responses to a clinical scenario then share the percentage responding to each of five alternatives. Clinical Survey provides questions with expert commentary; many are excellent, although several (such as HRT) need subtle updating, and all original content should be dated.

Communications, POL's strong suit, includes a full range of e-mail, messaging, chat, and discussion group services. The latter is discussed in detail under Communications. For physicians who enjoy online banter, this is the service to beat.

New management features and proprietary software are business-savvy and may (or may not) compete favorably with more fledging services, but they don't compensate for POL's weaknesses and lack of sophistication. By deemphasizing in-your-face banners; by giving greater attention to Web site design, organization, and maintenance; and by continuing to develop strong clinical materials and links, POL should be able to attract and service all types of physicians.

Sections Medscape
last visited November 1998

Medscape, "the #1 free Medical Internet Site" created in 1995 by SCP Communications, has grown into the independently owned and operated Medscape, Inc. Its board of directors includes leaders in business as well as Web technology, and its editorial director is a physician assistant credited with much of the clinical and technological vision behind the original, and future Medscape.

Everyone, from physicians to paraprofessionals to patients, visits Medscape. Admirably, the site bucks the trend by remaining focused on medicine. It services its broad clientele by posting a medical dictionary, publications like Hippocrates, and a health sciences Career Center. But the centerpiece of the site remains its physician-directed content: thousands of clinical review articles from its Publisher's Circle of 35 minor medical journals. Content is variable and newer articles are rarely linked to Web sites anymore, a feature that is sorely missed. Future plans include original clinical content written by physician experts for their peers, and its own medical Web search engine and reference.

Among physicians, Medscape is best known for its online CME, where $50 buys a year's worth of credit from over 200 articles. The CME program also has six free corporate-sponsored programs. New services include e-mail and a free drug samples system, presently in beta testing. Another new feature is Journal Scan, where groups of articles from the major journals in one of five specialties are summarized every week or so.

A search engine and links to sections and other features border the multi-specialties (default) home page; the center is filled with annotated links to new articles. Technically, Medscape is well constructed, with an orderly layout of sections and subsection home pages. Navigation throughout the site and within a page is intuitive and is aided by the consistent interface and tool bars, although slowed somewhat as banner ads on the top and bottom of most pages refresh. But Medscape wisely allows its ads to scroll off for those who read on line.

The site's content is divided into overlapping sections: Specialties, News, Journals, Patient Information, Exam Room, Library, and Services. Each section consists of one or more subsections, each in turn with its own home page. One clever feature is that registrants may select one of 19 specialty home pages as their default page. An ever-present engine allows searches in Medline, Aidsline, or (unique to Medscape) Toxline, a drug reference, a medical dictionary, and the site itself÷which is divided into articles, news and discussion, and patient education. Both keyword and free-text search is available, articles can be searched by month up to three years back, and hits can be prioritized by either date or relevance.

The News section is headed by daily consumer health news from MSNBC and Reuters, though more professional resources are available at mid-page. Buried within news, Medscape's Conference News Online deserves attention. These are physician reports on presentations at meetings, scientific sessions, and conventions, many posted the same day and some carrying CME. Others are associated with journal reviews, and a few include multimedia.

Other features are less impressive. The cleverly titled Exam Room section is full of basic quizzes and largely forgettable pearls. Clinical Discussion is an ambitious but underutilized feature; the Spotlight discussions were especially good, accompanied by well-written summaries and links within Medscape and throughout the Web, but ended in 1997. Online textbooks are chapters in books about bone density measurements and vector analysis ECG. There's a section for Patient Education handouts, mostly MicroMedex's information-lite CareNotes, and government and association handouts divided into about two dozen specialties. FirstDataBank's Drug Search is most useful for drug interactions, though some may enjoy its list of medications to treat or avoid in specific diseases.

Medscape's metamorphosis over the years has been a Web success story. Though it is no longer defined by its throwaway journal image, Medscape's clinical content still isn't highly regarded by most physicians. Continued metamorphosis is a laudable, and challenging, goal.

Sections Other Services
last visited February 1999

Medical Economics' interactive site for physicians has undergone several major transformations over the past few years. Its latest version,, had changed its suffix (from com) though not its focus on marketing and advertising. But the new name better reflects the site's major resource: its free online Physician Desk Reference and Addenda. Kudos to Medical Economics for providing this generous database, alas not its most updated version. Other resources of interest to physicians include full text minor medical journals published by Medical Economics -- Medical Economics, Patient Care, Drug Topics, Internal Medicine, and the Contemporary series (OB/Gyn, Pediatrics, and Urology) among them. Other databases include Reuter's Health, the Red Book, Stedman's medical dictionary, and professional directories on hospital personnel and managed care organizations.

Overall, the site's content is essentially unchanged although the presentation is vastly improved -- both more sophisticated and user-friendly. This site has a number of interfaces, only one of which caters to physicians; is also available to "consumers", nurses, pharmacists, and physician assistants. Everywhere there are easy links to other Medical Economics' sites, and to patient resources.

Hot off the presses, InteliHealth Professional Network (IPN) describes itself as, "an exciting new initiative by InteliHealth, Perot Systems Corporation and PointCast Incorporated to create the first Internet broadcast environment for healthcare professionals." Sources of information include the NIH, AMA, FDC Reports, Reuters Health, U.S. Pharmacopeia, Silverplatter Information, and Williams & Wilkins among other publishers. Although the site appears designed for healthcare professionals, a glance at the professional drop-down list which registrants complete anticipates mostly non-clinicians and allied health workers.

Like services reviewed above, IPN provides access to Medline, health news including Reuters, a medical dictionary (Taber's, in this case) and its own drug reference (USP DI). The best section is Health Resources, which provides both private databases and links into the medical Web using a menu-within-menu format. Medline search engine links to InteliHealth's consumer site, which is "powered by" HealthGate and includes other NLM databases such as AIDSdrugs/AIDStrials, AIDSline, Cancerlit, and MDX Health Digests, the latter a fee-based consumer health database on HealthGate. But throughout, links are incomplete or inactive. For example, the fee-based Journal Watch section includes 2 years' worth of review summaries, but only the links to the most recent few seem active. Other sections, such as Career and Education, are also inconsistently maintained.

With its clean interface and content drawn from propietary databases and medical Web links, IPN has almost as much in common with the new online services described in a companion NetView. This site has the potential of developing in one of several directions, depending upon whether it follows its strengths or its less professional features.

Other medical megasites: Doctor's Guide to the Internet maintains press releases on medical news and therapies, and medical conventions and meetings; other listings are relatively stale. One of the earliest Web design companies, the similarly-titled Physician's Guide to the Internet puts physician lifestyle up top, but includes an array of clinical and professional resources for doctors and students. For physician researchers, BioMedNet is an attractive site with an excellent Medline search engine and electronic journal HMS Beagle among its many features.

A perennial favorite, MedConnect describes its focus as "clinical and practical", but the heart of this free site is clearly educational. MedConnect has been developing medical content for emergency and primary care physicians since 1994. Its staff includes a medical editorial board, and academic physicians write all original content. Banner advertisements are largely (not entirely) confined to MedConnect's sister site, HealthAtoZ, which includes health news and an engine that searches their often-outdated catalogue of inconsistently rated medicine and health sites. Otherwise, MedConnect is a self-contained site without links to the Web.

The site's main content is divided into five electronic journal-type sections. The best is iPEDS. Among its features are a series of cases, journal reviews, and an advice column on child development issues. STAT covers emergency medicine, which continues to post interesting toxicology cases but the rest of the features, including its once-wonderful monthly journal reviews, are now quarterly at best. Prime Connection is directed at primary care physicians, and boasts a well-maintained list of new therapies (the site's only drug database). Managed Solutions has a number of practice-oriented articles and a biweekly series, News & Views, which summarizes activities in the field. Family Practice Resident is free but requires a separate registration, and appears to emphasize online discussions. A Boards Review section should be of interest to practicing physicians seeking recertification as well.

The CME section gathers all eligible text articles under the headings of Managed Care, Family Practice, or (outdated) Emergency Medicine. The Medicine section has a redundant link to CME Center; a basic but nicely programmed Medline engine; and Chest Radiology Files, a collection of teaching files with reasonable quality films. Lastly, the Connection section is a non-comprehensive list of jobs, conferences, chapter information, and humor.



Sections Search Engines

Every U.S. citizen on the Internet has free access to Medline and other NLM databases, such as PubMed. For clinicians, understanding a search engine's features, limitations, and idiosyncrasies is as important as taking the time to master it.

Both Reutershealth and Physicians' Home Page (PHP) use different versions of Silver Platter's WinSPIRS search engine, but that's where the similarity ends. Reutershealth's search engine has limited search options and its initial results page, like that of Physicians' Online (POL), has no author, date, or journal title accompanying its hits. Further, Reutershealth's Medline Express database appears not to have been updated since February 1998. Using either Reutershealth or POL, I was unable to obtain the best collection of articles relevant to my search terms.

In contrast, PHP's fee-based WebSPIRS engine, described as a specially designed version of SilverPlatter's full search engine, has been favorably reviewed. I also found its online documentation especially useful in manually refining searches, although I had difficulty setting the date parameters.

Many physicians prefer to sacrifice power for ease of use, especially for more straightforward searches. The BioMedNet search engine uses a minimalist template, yet allows for manipulating key parameters and saved searches. Another alternative for quick searches is Infotrieve Online, available also through Medconnect. This is a basic search engine with access to natural language and Boolean operators, a number of field limit parameters, and the ability to combine searches through search history. Like HealthGate, MedConnect offers an intermediate results page with relevance ranking and article title, author, journal and month/year of publication÷features I miss in POL and Reutershealth. Unique to MedConnect, selections can be displayed in a variety of formats. Online document ordering is available here, as at most other services.

For users who require advanced search features such as limiting to certain journals or author search, and databases other than Medline, HealthGate is the better option. Similar to MedConnect in design, HealthGate includes an advanced search template and access to six other NLM databases. The tradeoff: HealthGate's intermediate page has no relevance ranking and no easy way to change display formats. Also, users who are not paying members of MedGate will confront banners as they search.

Those who find abstracts unsatisfying or who wish to expose students and house staff to primary references may conclude that fee-based MD Consult is worth the price. MD Consult also provides searchable (alas, not direct) access to dozens of Clinics of North America and Yearbook series, with their variable but occasionally outstanding review articles and commentaries, respectively. Unfortunately, aside from limited access to core medical journals, I found MD Consult's search results quite unreliable compared to other engines. In discussing this with staff, I was told the engine searches the full text of articles in addition to title and abstract, and doesn't set journal priorities. As a result, hits from the more appropriate, higher quality journals not carried by the service would appear low down on the results. MD Consult should provide manual control over these features for those who need to perform accurate or comprehensive Medline searches.

Sections Textbooks

Computer access to textbooks can help the user better search and navigate content, improve storage space and transportability, and allow for ease of update. I've heard some physicians grumble about MD Consult's limited text offerings but marketing hyperbole, inelegant interface, and navigation difficulties aside, these 37 texts provide a reasonable basic medical textbook reference for most educational and clinical purposes, and even more volumes are promised in the future.

MD Consult's competition at present comes from advancing Web technology. For example, an online textbook's core material can be periodically updated, such as the fee-based Harrison's Online and Scientific American Medicine, or PDR Addenda available through Electronic textbook competitors with frequent updates include the advertising-supported Emedicine and Outlines of Clinical Medicine, the latter accessible to registered users of Avicenna as well as POL.

Sections Journals

The five top medical journals÷NEJM, AIM , JAMA, BMJ, and The Lancet÷are all on line, and we Yankees are put to shame by the white coats across the Atlantic. BMJ's Web site is one of the best: generous with free content and wonderful article links, an intuitive interface, and several other unique features. The elegant Lancet site instructs hospital-based physicians on gaining free access to its full text articles. NEJM, on the other hand, has limited its on line content, as have JAMA and AIM.

Nonsubscribers desiring full text access to America's major medical journals should investigate Ovid's Core Biomedical Collection. For other journals, Medscape links to the Dow Jones Publication Library, a group of 5,500 publications including 50 professional medical journals such as JAMA, Chest, and Pediatrics. Articles are only $2.95 each. And those looking for a day's access to many full-text articles will appreciate MD Consult's Express Pass at $6.95, although access is only through a search engine, not by issue, and without full-text articles, among others, from the five major medical publications.

Hundreds of journals are available on line, and several online services, such as POL, links to some of them. PHP's list of journals is more comprehensive but poorly maintained. For one of the most complete listings, see Sweden's Karolinska Institute Electronic Journals. BioMedNet Library complements medical journal articles with those on research and applied physiology, and includes access to current and past issues from the Current Opinion series.

Medscape and Medical Economics', the latter freely available to physicians who register, allow both search engine and individual issue access to their sponsoring and parent companies' minor clinical journals.

Sections Original Content

See Frequently Updated Medical References for a list of summaries and/or commentaries accompanying new journal articles and abstracts, many with interactivity or an evidence-based slant.

Current journal summaries also appear on three services. Of these, MD Consult's This Week's Journals provides the most comprehensive resource, covering all five major medical journals and a number of specialty journals; moreover, it links each article to textbook and full-text journals within MD Consult. Its source material, however, is often Reuters articles, which is fine for news, but here may exclude aspects germane to clinicians. PHP's MD Digests, written and edited by physicians, is more clinically accessible and is also archived, but is limited to single articles appearing twice weekly. Links to preformatted Medline searches and Web sites are not always ideal. Several times a week, Medscape's Journal Scan briefly summaries recent clinical articles in one of five specialties. Links are to the article abstract or full text when available, and issues are archived.

Purists may simply prefer quick access to a primary source. POL provides direct links to the latest issue of all five major medical journals, and Silver Platter's WebMedLit allows for easy searches to the latest issues of a group of solid journals, including three of the five major medical journals. An annotated listing of over a dozen current journal issues, and citations and abstracts, is included at Frequently Updated Medical References.

Topic overviews, another category of original clinical content, can be an enjoyable way to learn and refresh. But content must be accurate, comprehensive, and (ideally) peer reviewed or at least edited for content, not just copyedited÷and many are not. Fees and heavy sponsorship are no assurance of quality; perhaps the best original content can be found on medical education sites. Weak content was noted in passing on PHP's MD Opinion and Medscape's Virtual Consult, although both include excellent work as well. Blatantly incorrect or misleading clinical material and errors of omission were found in MD Consult's Tours and other minor features. For lighter fare, POL and Medscape have clinical quizzes and interactivity.

Sections Online CME

Medical education has exploded onto the Web and those interested in exploring online CME will appreciate Medical Matrix and MedWeb. MCToday also supports an annotated list of Online CME sites. Unfortunately, the Web's search limitations are felt even among these fine lists, in that no resource catalogs by specific topics. For example, it was only by browsing that I discovered both Medical Direction's Virtual Lecture Hall and Cyberounds' Hematology/Oncology section offer recent and complementary material on non-small cell lung cancer.

Five of the six reviewed online services offer good CME, for free or an additional fee. Dozens of SilverPlatter's Virtual Symposia are freely available, but PHP members are eligible for free CME as well. POL's CME section includes its own Controversies in Cardiology and links not only to Virtual Lecture Hall mentioned above but also to Cleveland Clinic Journal of Medicine Online CME. MD Consult posts 14 subscription-based clinical newsletters from American Health Consultants. HealthGate offers about two dozen didactic courses in a variety of clinical specialties, sponsored by Boston University Online CME. A few include graphics, and the resource is frequently updated. Medscape has seven programs for CME, which include material from hundreds of articles in its Conference News Online and patient cases.

Sections Medical News

Access to medical news is a Web strength, as evident in the many fine links in Medical News on the Web.

Several services excel in individualizing and combining resources. MD Consult links medical news articles (in this case, from Reuters' fee-based Medical News) to journal abstracts and full-text references. It's quite illuminating when, for example, the news story, "First human evidence that neurons replicate in adult brains reported," is linked to a 1996 abstract, "Neurogenesis in Adult Human." MD Consult's news stories are solely clinical. For example, "Health, financial leaders meet to discuss WHO tuberculosis initiative" links to two quality full-text articles about drug-resistant TB, but it has no database from which to call forth the complicated history of international politicking behind this WHO "initiative."

MedGate also links to Reuters' Medical News, but see POL for identical articles grouped into topics for easier scanning, and for a search engine to 30 days of news archives. Further, POL includes Medical Tribune articles, specialty news, meeting highlights, federal government agency news, and medical news weekly highlights. MedGate also links to Newswire clinical headlines, but freely available Newspage Healthcare has headings identical to Newswire's Clinical Areas and Pharmaceuticals÷and a slew of other health categories besides. And selections here include not only the headlines but a two-line article summary, along with convenient links to free or fee-based access to the full text.

Like POL, Medscape includes meeting highlights, federal government agency news, and medical convention news, with a broader appeal than just to physicians. BioMedNet's new feature, BioMedNews, includes news and convention reporting, with a neuroscience slant. From a physician's perspective, Reutershealth's fee-based service does little to improve upon its own database, although medical writers and others will appreciate its basic and advanced engines that search up to six years' worth of news archives. Subscribers accessing the health or medical news sections will also find all medications mentioned in the article linked to entries from service's drug database, a unique feature among news repositories.

Sections Communications

Whether the result of time constraints, privacy concerns, or just plain disinterest, physicians have not embraced online communications. But the circumstances under which physicians are most likely to communicate may be less elusive than the hundreds of empty threads and cries-in-the-dark postings seem to suggest.

For example, physicians will ask questions and share information, even in a public setting, if led there by excellent content and facilitated by knowledgeable, congenial colleagues, assuming the interface is comfortable to use. Journal Club on the Web demonstrates how content and nurturing can encourage thoughtful posting. Similarly, articles linked to discussion groups can be found on Medconnect, Medscape, and POL.

MD Consult created a handful of discussion sites for its subscribers, but more often than not its relatively few posts go unanswered or poorly answered. Part of the problem lies in MD Consult's buggy posting format, and lack of good facilitators and quality content to unite them.

In many ways POL has set the standard for physician Web communication. One of the first to offer free e-mail to its members, POL now boasts a much improved mail program featuring an address book, a medical and English spell checker, and the ability to store old e-mail in personalized folders. Online instructions allow users to access their POL mailboxes through another ISP and compose e-mail off line. Medscape's free e-mail service isn't nearly as accommodating, although newcomers as varied as Healthprovider.Com and WebMD provide new communications features that may challenge POL.

Other site conveniences include identifying who's on line, instant messaging, online chat rooms, and very active discussion threads covering every imaginable clinical topic, policy issue, and personal persuasion. Discussion Groups are divided into clinical specialties and general topics, and a less formal Clinical Forums section accessible by members of both POL and its sister service, Health Professionals' Online. With so many members and active threads, the momentum is self-perpetuating. But designated physician-facilitators keep the fires stoked by submitting posts on selected journal articles or adding a clinical fact or reference.

POL fosters a communal spirit in other ways. In addition to its solid technology, discussants can elect to be identified by anonymous tag rather than by name. In an all-physician environment, anonymity allows participants to discuss sensitive topics like physician-assisted suicide, sexual issues, and professional impairments. POL threads may be more literate and thoughtful than the majority of online discussions, but it still lags behind the more informative and newsy content of closed professional e-mail listserv groups.

Sections Musings

Each service uses computer technology to transmit medical news and clinical references, to support community-building interactivity, and even introduce secure data transmission and receipt, yet no service has seized the opportunity÷or even seems to recognize the need÷to educate physicians about computer technology's impact on medicine. Consider some of the many ways computers are reshaping health care: through telemedicine, which allows long distance consults, home monitoring, and patient communications; transforming specialties like emerging infections or new paradigms such as evidence-based medicine; in patient medical record keeping, issues involving standards and confidentiality; in practice management and monitoring practice parameters, such as outcomes; and in computer-assisted medical education and online CME.

It's not for lack of skill or creativity. POL is giving away software specifically designed to exploit computer technology for practicing physicians, Silver Platter dominates the industry in CD-ROM-based medical education, and MD Consult is breaking down walls between publishers to create a shared clinical database. Are all these services using their vision only to look for the nearest dollar? Or, like physicians, are they all still wrestling with computers, trying to understand the technology that is transforming medicine, publishing, and business?

Disclosure: The author has published work in an American Health Consultants' newsletter and Emedicine.
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