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Br J Clin Pharmacol. Jun 2006; 61(6): 787–790.
PMCID: PMC1885123

The internet as a tool in clinical pharmacology

Abstract

The invention of the internet and the world-wide web was a landmark that has affected many aspects of everyday life, but is so recent and dynamic that many of its potential uses are still being explored. Aside from its purely commercial use as a virtual pharmacy (e-commerce), the internet is useful in at least three aspects related to clinical pharmacology: communication, training and research. In this paper we briefly review several internet applications related to clinical pharmacology and describe, as an example, the logistics of a multicentre research collaboration related to the promotion of rational drug use in the prevention of postpartum haemorrhage.

Keywords: Internet, world wide web, clinical pharmacology, communication, training, research

Although the historical perspective is still too short, there is no doubt that the invention of the internet and the world-wide web [1] was a landmark that has affected many aspects of everyday life, including clinical pharmacology. On the other hand, this tool is so recent and dynamic that many of its potential uses are still being explored.

e-commerce

The advertising and sale of drugs through e-commerce is a very popular application of the internet and E-mail. Every day the inboxes of millions of users are filled with dozens of unwanted messages advertising drugs to improve sexual performance (sildenafil, tadalafil), to relieve panic attacks (alprazolam) or anxiety/insomnia (diazepam, zolpidem), to relax the muscles (carisoprodol), or even to prevent the threat of avian flu (oseltamivir). Thus, by massive advertising and facilitating access through global virtual pharmacies, e-commerce contributes to increased self-medication, the medicalization of everyday life and probably inappropriate use of drugs.

Pharmaceutical companies also have their own web pages, which include free-access information about their products addressed to healthcare professionals and users, sometimes including messages about diagnosis and therapeutics. Several manufacturers have specific web pages with a brand name as part of the url, which makes it very easy to go directly to them when looking up that specific product through any search engine, such as Google or Yahoo. The quality of drug information on the world-wide web has been analysed, and suggestions for improving it have been made [2, 3].

e-communication

Bibliographic searching has taken advantage of on-line access to electronic databases. The heavy Index Medicus volumes that stood on library shelves 10 years ago have been definitively replaced by easy-to-use search engines, such as EMBASE, Medline and PubMed, which in just a few seconds retrieve reference lists after Boolean searches using the appropriate keywords. Furthermore, the reference lists can be managed as word-processor files and direct and often free access to the full-text papers is available for a growing number of them, including back archives [4].

Recently, web programming has experienced remarkable advances – for example, the development of tools that use query language in order to facilitate the retrieval of information [5]. In addition, the impact of the web search culture is changing the way in which researchers look for medical literature, although at present many users prefer to retrieve references using Google or Google Scholar, even though there are persistent doubts about the quality of the recovered information [6, 7].

The evolution of the world-wide web to further a social concept (open access) is also influencing medical publications, and initiatives such as PLoS [8] or BioMed Central [9] tend to consolidate this, although doubts have been voiced, not about open access itself, but about immediate access that is free to readers and paid for by authors [10]. This, combined with new approaches to copyright (e.g. Creative Commons [11] and Science Commons [12]) provides a more flexible strategy for the sharing of knowledge.

Many clinical guidelines are also freely accessible through the world-wide web. As with paper versions of such guidelines, the accuracy and quality of the recommendations included in clinical guidelines that are posted on a web page must be routinely checked before adopting them. Beyond isolated clinical guidelines from drug industries or specific medical societies, there are several institutional web pages, such as the US National Guideline Clearinghouse [13], with a tool to compare the content of different clinical guidelines, or the web page of the UK’s National Institute for Health and Clinical Excellence (NICE) [14]. Prescription counselling initiatives, for example the Primary Care Question Answering Service of the National Library for Health (NLH) [15] and ATTRACT [16], are also proliferating.

An additional and perhaps more interesting use of the internet is communication via electronic discussion lists (EDLs). Virtual communities of professionals interested in a specific topic meet to exchange information, address queries and discuss the topic, thus greatly enriching the process. Electronic discussion lists have also been shown to be very useful in bringing information that is otherwise inaccessible to professionals working in less well-developed settings, because a personal computer connected to a telephone line is a powerful tool for receiving news. As examples, the electronic discussion lists supported by Satellife and the World Health Organization (‘e-drug’ in English, ‘e-med’ in French, ‘e-farmacos’ in Spanish and ‘e-lek’ in Russian, launched in 1997, 1998, 2000 and 2003, respectively) provide references in the area [17]. With a wider scope, the ‘HIF-net’ initiative [18] is a forum launched in 2000 by the International Network for the Availability of Scientific Publications in collaboration with the World Health Organization in order to share ideas and insights for improving access to relevant reliable information for healthcare workers.

e-learning

After an initial period of doubt concerning the quality of transferred knowledge compared with traditional training, e-learning has become a flourishing education area. With further outreach than conventional distance learning, and taking advantage of interactivity among students and teachers in a virtual community and hypertext and hypermedia facilities, e-learning has become a useful and widely accepted tool for postgraduate training and continuous professional development programmes. The number of e-learning products that involve therapeutics is growing; as examples, consider the innovative British Medical Journal learning initiative [19] and the UK’s NHS Appraisal Toolkit portal for clinical governance in the NHS health community [20].

Recently accumulated experience has developed into the emerging concept of Web 2.0 [21]. This new approach does not imply that traditional websites will disappear, nor the classical electronic journals. The idea starts from the view that networking is almost essential for current research, so the use of tools that allow or facilitate collaborating links and participation from a constructivist point of view, without caring about time and distance, seems unavoidable [22]. In fact, discussion forums, blogs (web logs) and wiki sites are alternatives that favour sharing, in order to generate knowledge from a conversational approach. The BMJ’s ‘rapid responses’ section [23] was among the first medical examples of this idea.

Wiki webs are the most proliferating world-wide web tools [24]. ‘Wikiwiki’ means ‘quick’ in Hawaiian, and wiki is also said to stand for ‘what I know is …’. Wiki is an application that allows users to create html web pages, with the enormous advantage that users do not need to know html syntax – only very simple syntax rules are necessary, similar to what is needed for any word processor. In addition, wiki applications allow many attachments (e.g. images, sound), permit strict control of updated versions and can be accessed remotely through an ordinary navigator. Access to a wiki can be opened or restricted to a group of authenticated users. Wikipedia, an open global encyclopaedia [25], is the best-known wiki project.

Sharing the drawing up and refinement of the contents of a project within a network in a centralized way can be useful for many research initiatives, including research in clinical pharmacology and pharmacoepidemiology (e.g. intranet, multicentre collaborations, or project development).

The GIRMMAHP experience

Since 1985, the Foundation Catalan Institute of Pharmacology (Foundation Institut Català de Farmacologia, FICF, Barcelona, Spain) has been working on research projects aimed at promoting the rational use of drugs and pharmacovigilance, in collaboration with research and teaching centres from several Latin American countries. In 1991 the Drug Utilization Research Group Latin America (DURG-LA) was founded, with the aim of contributing to the creation of a network of health professionals working in this area [26]. The group includes GIRMMAHP (Grup Internacional per a la Reducció de la Mortalitat i la Morbilitat Associades a l’Hemorràgia Puerperal), which is a multinational collaboration, founded in September 2003, for improving the quality of delivery care in order to reduce maternal morbidity and mortality due to postpartum haemorrhage; it is active in Argentina, the Dominican Republic, Guatemala, Nicaragua and Peru.

The logistic challenges related to setting up and developing such multicentre initiatives, and the usual economic limitations to projects funded by public grants, prompted the coordinators to look for new strategies. The basis was a restricted-access wiki space, which reduced the number of expensive coordinating meetings and the need for intercontinental travel. After a first meeting in Lima, Peru, the GIRMMAHP wiki allowed the group to discuss the design of the full project, the activities to be developed in each phase of the intervention (drug utilization studies before and after educational interventions) and the sharing of different databases containing information about 10 drug utilization studies, and an analysis of the results. Figure 1 shows an outline of the dynamics generated in the wiki working area.

Figure 1
Evolution map of content in the GIRMMAHP TWiki site [27]

Despite geographical distances, the electronic tool improved cohesion among 12 participants located in six countries and improved resolution times of tasks and the quality and degree of shared additional material used during the interventions in each location (text, data and graphics). Part of this material and the results of the intervention are being posted in an open-access twiki (structured wiki) web page [28]. Last, but not least, part of the saved costs for international meetings and long-distance phone calls could be reinvested to expand the intervention.

Acknowledgments

To Carles Figuerola, from Informatics Unit, Fundació Institut Català de Farmacologia, for the Twiki design of http://www.girmmahp.net. GIRMMAHP has been partially funded by the Agència Catalana de Cooperació al Desenvolupament of the Government of Catalonia. Additional GIRMMAHP participants who exchanged data and information through the Twiki project are: Edgar Narváez (Nicaragua), Angiolina Camilo (Dominican Republic), Susana Vásquez and Germán Rojas (Peru), Mabel Valsecia (Argentina) and José María del Valle (Guatemala).

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