The Internet

The World Wide Web is less than 20 years old at the time of writing this book. Yet it contains several billion pages and has become woven into the fabric of everyday life, especially in the developed world. The Internet in its current form came into being in 1983. The web took form around 1989/90, was launched in 1991 and came into widespread use from 1993 onwards. From the beginning it acted as a place where large numbers of files and documents could be stored for download, circulation, discussion and communication. These days many thousands of documents and other items are added to the web every hour. Consequently it is not possible to categorize all available websites in order to create a comprehensive directory of the web. Most people create their own directory of useful websites or search the Internet for the information they need.

The web address

The term website is used to denote a set of themed, linked web pages, usually accessed via a ‘homepage’. Web pages are written in hypertext mark-up language (htm). A web page is a collection of text, graphics, sound and/or video that corresponds to a single window of scrollable material. Web pages are stored on a web server, a program that hosts the website and ‘dispenses’ the pages in response to a web browser. The web browser displays web pages after communicating with the server. There are a large number of browsers in existence, although currently the majority of users in the western world employ either Internet Explorer^® or Netscape Navigator^®.

Each page on the web has a distinct web address known as the uniform resource locator (URL), sometimes referred to as the uniform resource identifier (URI). The URL can be a good clue as to the quality of the information found on a website; this is covered in detail, below. The ‘locator’ in URL can also give an indication of where one is within a website; for example, on the homepage or further in. The locator can also indicate the source of the information being viewed; for example, whether it is from the Department of Health or a pharmaceutical company.

A web address or website name appears on the address bar. All website names are part of the domain name system (DNS) and look similar to this: http://www.dh.gov.uk/.

Box 23.2 breaks down this address and examines the individual parts. In summary, the web address http://www.dh.gov.uk/Publicationsandstatistics/index.htm is showing: protocol://server.name.domain.country/pathname/document name.file extension.

Bookmarking

Readers are encouraged to set up their own bespoke directory of health- and medicines-related websites that they can update as required. Once a number of relevant websites have been identified and authenticated for inclusion, a simple way of starting the collection is to store the directory as a saved text file, using hyperlinks to connect each typed URL address in the document to the address bar on the browser and therefore the desired web destination. Hyperlinks are usually in a different colour to the rest of the document or are underlined and can be activated by a mouse click.

Hyperlinks also provide a useful way of finding and bookmarking other useful websites from existing ones. Websites normally have a directory of related websites as ‘links’. By clicking on a link, a request is sent to the computer that holds that information, asking it to send it to your screen. Following these links on the screen is known as ‘browsing’, sometimes referred to as ‘surfing’.

A well-accepted method of bookmarking relevant pages is to use an Internet browser with functions such as ‘Favourites’, ‘Bookmarks’ or ‘Hot List’. A marker points at a website which then enables the user to quickly return to that site without having to remember and type in its URL. In this way, the ‘Favourites’-type function acts like a conventional bookmark. Browsers usually offer the facility for organizing the bookmarks into folders and subfolders.

There are also innovations such as the social bookmarking website http://del.icio.us, which provides a means of storing personal bookmarks online instead of within the browser, thus enabling bookmark information to be accessed and shared online.

Commercial search engines

The Internet is not controlled or owned by any individual or organization in particular. Unlike a catalogue, which is normally a well thought out record created and maintained for a purpose, the Internet plays host to a multitude of material with limitless authors. The Internet is vast but far removed from a library of approved and organized material. The manner in which information is stored on, and then retrieved from, the Internet is quite unique. There is no central catalogue of the Internet and no ‘people’ physically vetting the web to create large-scale records. Instead, computers are used to create indexes of the web.

A variety of websites concentrate on providing Internet search facilities. Some are set up as web portals with the aim of providing a complete resource for everything on the web that they consider to be worthwhile. Portals display their own editorial material, news headlines and other up-to-date information, as well as links to commercial partners and paid advertisements. They are good for general or commercial information but most will fail to identify websites for non-profit organizations such as the NHS. Web portals also provide a search facility. Examples of web portals include Yahoo^®, MSN^® and AOL^®. Other websites concentrate purely on providing a search facility; examples include the search engines Google™, Altavista^® and Ask™. Search engines attempt to search all the text on all the pages of the web. They use software to seek out and index web pages, storing the results in sizeable databases. Essentially they are clusters of powerful computers, endlessly navigating the web and building indexes of pages based on words and links found on those pages. When a user types a query, the search engine searches its database for pages that contain words matching the query and displays the results as a list of links. Box 23.3 gives a more detailed explanation of search engine components. Each search engine ranks results according to its own criteria and so different search engines can give different results for the same query. Search engines are useful for finding obscure information or for some research-type activities. They may, however, retrieve a multitude of items that are of little or even no relevance to the search activity.

Effective use of search engines

An informed approach to using search engines for health- and medicines-related information starts from an insight into the workings of these, as detailed above. Before beginning a new search, the user should take time to consider what they already know, the knowledge gaps and the types of information required. It is always advisable to have a plan so as to focus the search. The user should carefully select a set of keywords that best reflect the information need and narrow the search to a particular subject or topic. Any subsequent search results should be compared to the original information need. If appropriate material is found on the first page of the search, the activity need go no further. It is especially important to know when to stop searching, especially when there is a time limit on the search activity.

When, however, the results do not match the information need, for whatever reason, it is advisable to pause and reflect. The user should take time out to consider what they are searching for; can the search be refined, by changing keywords, perhaps adding, taking away or replacing them? The keywords must match the information need. One additional approach is to subtract any redundant words from the search query. These include words such as ‘a’, ‘an’, ‘the’, ‘and’, ‘in’, ‘any’, ‘my’, etc. It might also be helpful to rearrange the search so that the more important search terms are placed first, to give more influence when the results are ranked.

Most search engines provide guidance on their specific ‘operators’. For example, Google™ provides a list of its most popular tools for refining searches under its ‘cheat sheets’. Boolean terms for academic databases are described in more detail in the sections below. In Google™, the Boolean terms AND and NOT are not used in the traditional sense. Google™ will automatically link a series of words using the AND operator. Instead of NOT, to eliminate a word from the results, a space should be left after the word that is needed and a minus sign (−) should be typed immediately before the word that is to be excluded. The term OR can, however, be used in Google™ by typing OR between the words. Google™ can also be forced to link words by using a plus sign (+), especially where one of the words is a common word that might normally be ignored. The search engine can also be asked to search for a string of words in a particular order, for example ‘Community-acquired pneumonia’. The user should examine search engine tools to make the most of any advanced features beyond the basic search box. Sometimes, the search engine itself may need to be changed or the basis of the search re-examined.

It is important to recognize that search engines do not necessarily index the whole of each document they retrieve. A search engine may upload each page in full, but it may only use the first few thousand characters for indexing. Therefore, should the vital information exist further down the web page, beyond where the robot will read, it will escape being indexed. Where a search engine does return a link to a site, sometimes it is not possible to access the content if the user is behind their organization’s ‘firewall’. This is because some organizations either block content from a list of undesirable websites or will only allow content from a list of desirable websites. Also, search engines do not locate everything on the web first-hand. It might be that a general search engine finds another site that is a more appropriate starting point, for example a health services directory. In that way, the search is narrowed automatically from a general search engine to a topic-specific one.

Some public web pages are protected from search engines through use of a file (robots.txt) that blocks access to the robot. This normally relates to personal, sensitive, interactive, timely or premium (subscription, or paid for) content. The robot is excluded from a page, the search engine does not get to index that page, and thus will not return it as a result. Another place that search engines cannot always reach is commercial data collections, or collections of valuable, copyrighted content, such as subscription-based academic journal databases and other specialized databases, information in professional directories, patents, and news articles.

Assessing the quality of information on the web

There is no restriction on what is placed on the web, by whom or from which geographical location. There is certainly no process of editorial or peer review for material placed on the web. No UK organization is currently responsible for regulating health- and medicines-related information on the Internet. Under these conditions, there is always the danger that an Internet site contains incomplete, inaccurate, irrelevant, obsolete or even hoax information. As a result, the utmost care should be taken in making use of health- and medicines-related information from the Internet. An informed approach must include a system for evaluating the quality of the information found against the intended use of that information. No single quality indicator exists; the user must piece together a variety of indicators to assess the value of the website on its merits. Factors listed below can all affect the quality of an information source; they are not mutually exclusive and must be considered in combination. Table 23.2 provides summary guidance on evaluating the quality of a website.

Table 23.2 Evaluating the quality of an Internet-based website for health- and medicines-related information

Primary reference sources

The primary literature is the basis of the information hierarchy, leading to the development of secondary and tertiary literature, although with variable time lags. The term primary literature is used in essence to refer to original publications and normally entails research papers published in journals, although it can include other material such as case reports, case series, editorials and letters to journal editors. Preliminary research findings are sometimes presented at conferences in the form of poster or oral presentations. A record of these is normally published in the conference abstract book or the conference website. Sadly, conference abstracts are the only place that some research ever materializes in an original form; this is especially so for some pharmacy practice research.

Secondary reference sources

Secondary information sources can be used to locate primary literature. In general, secondary reference sources are searchable resources that index and/or abstract from the primary literature. Some are equipped with alerting systems, which scan selected journals as soon as they are published and send summarized abstracts directly to users to help them maintain a knowledge – albeit superficial – of new developments from a large pool of journals. Nowadays, the data format used for providing users with frequently updated content is known as a web feed. A recent addition to web feeds is the RSS (really simple syndication) feed, which contains either a summary content from an associated website or the full text. RSS can be read using software called RSS reader or feed reader. The user subscribes to a feed by entering the feed’s link into the reader or by clicking an RSS icon in a browser that initiates the subscription process. The reader checks the user’s subscribed feeds regularly for new content, downloading any updates that it finds.

Secondary reference sources are generally searchable electronically but may also be available in hard-copy format. Secondary reference sources include commercial academic databases, resource gateways (collections of sites that have been reviewed and in some sense approved by the gateway maintainers) as well as the more recent academic search offerings of Internet search engines such as Google™ Scholar and Microsoft^® Live Academic.

Tertiary reference sources

Information from primary reference sources, perhaps retrieved using a secondary reference source, can in due course come to be included in textbooks and similar tertiary publications. As mentioned above, tertiary reference sources provide an overview of a topic in a condensed readable form with authors drawing on the primary literature for material. Examples are textbooks, drug compendia and formularies. A wide range of tertiary reference sources covering all aspects of health- and medicines-related topics exist. Key publications include Martindale: The Complete Drug Reference, and the British National Formulary (BNF). There are also textbooks covering specific subject areas such as drug interactions, adverse drug reactions, pharmaceutical compatibility and stability, complementary medicines and drug use in specific patient populations (e.g. children, the elderly, renal impairment, pregnancy and breastfeeding). Table 23.5 lists some of the key tertiary drug information resources for practising pharmacists in the UK.

Table 23.5 Key tertiary drug information sources for pharmacy inquiries (further details available on publishers’ websites)

Textbooks are important for locating established knowledge or information that is not rapidly changing. The information in a tertiary source is updated against new information or knowledge documented in the primary literature only once every 3–4 years, when the book is updated and published as a new edition. Thus it can take 5 or more years for new research findings to filter into medical textbooks. In addition, most books are out of date almost as soon as they are published. Time constraints in editing and publishing mean that it takes a year or more between the author’s submission of a manuscript and actual publication of the textbook. Because the knowledge base in many areas of therapeutics is rapidly changing, the information contained in textbooks may be too old to be useful. This problem does not apply, however, to those textbooks available in electronic full text as these can be more regularly updated, usually every few months. Another important exception is the BNF, which is updated and published as a new edition every 6 months.

Tertiary references should be the first port of call when trying to find background information on a subject. With the advent of the electronic age, it is easy to forget that information can be found quickly and easily in the humble book. Books are easy to handle, readable, contain concise information and are indexed.

Having said that, the reader must also be aware that the information presented in a textbook is subject to the opinion, evaluation and bias of the author. It is often assumed that what is written in a textbook must be accurate; in fact, the author(s) may not have comprehensively searched, analysed or interpreted all information. The information contained in textbooks may also not be as comprehensive as the reader would like. This may be due to factors such as restriction on chapter length or the degree of emphasis that the author has placed on each topic. Because they cover topics very broadly, textbooks are often poorly referenced, indicating only the most significant papers to support or refute a stated case. A reluctance to use textbooks is especially evident in the newer generation of pharmacy students used to the immediacy of information on the Internet. But especially in comparison to user-generated websites such as Wikipedia, good textbooks are an important and reliable resource and they should not be overlooked.

Organizing and citing references

For academic work, it is often necessary to store a relatively large number of retrieved citations. It is always advisable to implement some system for keeping track of the information amassed. A number of bibliography management systems exist for this purpose. Examples include RefWorks, EndNote^®, Reference Manager^® and ProCite^®. These products help users create personal databases. They enable users to import, organize, manage and export citations, to create reference lists and bibliographies for written academic work such as projects, reports and papers.

A number of referencing styles exist for citing retrieved information. Most academic institutions and publications have standardized requirements. Some of the more widely used citation styles are listed in Box 23.7. Whatever style is used, accuracy, clarity and consistency are the key factors when citing information sources. Guidelines for citing electronic sources are not yet fully standardized because these sources, which include the Internet, are constantly changing and citation formats have to adapt to these changes. See Box 23.8 for some general reference formats. Most biomedical journals now follow the Vancouver/ICMJE referencing style. Readers are directed to the website of the International Committee of Medical Journal Editors for more detailed guidance (http://www.icmje.org/).

Avoiding plagiarism

As discussed, a citation is the formal acknowledgement of intellectual debt to previously published research. Therefore, referencing is a way of ensuring that due credit is given to other people’s work. It is sometimes easy to copy and paste from journal articles and web pages into one’s own work. While common knowledge does not need a citation or reference, taking someone’s work and not indicating where it came from is termed plagiarism and is regarded as an infringement of copyright. To attempt to pass off such work as one’s own is considered cheating. This is not appreciated in any field of work. Plagiarism is considered a serious matter and higher education institutions invest in plagiarism detection software to scan assessment material.

Medicines information services

The NHS Medicines Information service is provided by a network of 250 local Medicines Information centres based in the pharmacy departments of most hospital trusts as well as 14 regional centres and two national centres (Northern Ireland and Wales). The aim of Medicines Information is to support the safe, effective and efficient use of medicines through the provision of evidence-based information and advice on therapeutic use of medicines. The centres are staffed by pharmacists and technicians with clinical expertise, and particular skills in locating, assessing and interpreting information about medicines. Local and regional medicines information centres provide an enquiry answering service, to patient and healthcare professional enquirers, on all aspects of drug therapy. Over half a million enquiries are handled by the service each year.

In addition, the UK Medicines Information (UKMi) network produces a range of resources available through its own Internet site (www.ukmi.nhs.uk) or that of the National electronic Library of Medicines (NeLM) (http://www.nelm.nhs.uk/en/). They include the UKMi new medicines portfolio which comprises early horizon scanning information on drugs in clinical development through to evaluations of medicines once marketed. Via NeLM, UKMi also provides a comprehensive daily news service that includes in-depth assessments of key published clinical studies (known as In-Focus). The news service generates RSS feeds for a number of specialist libraries hosted by the National Library for Health. In addition, a number of UKMi specialist advisory services make their material available through NeLM, for example the drugs in lactation database. UKMi also produces ‘Pharm-Line’, a bibliographic database focusing on medicines management, prescribing and pharmacy practice (subscription based).

Royal Pharmaceutical Society of Great Britain information centre

There is an information centre based at the Royal Pharmaceutical Society headquarters in London comprising the Library and Technical Information Service. The information pharmacists in the Technical Information Service can help answer scientific and technical questions relating to pharmacy practice or continuing education from members of any branch of pharmacy. The subject scope includes advice on the usage and availability of proprietary and other medicinal products, adverse drug reactions and interactions, and the identification of medicines from overseas. The Royal Pharmaceutical Society Library in Edinburgh specializes in pharmaceutics and quality control. The pharmaceutics information service is provided by the society’s fellow in pharmaceutics. It is a problem-solving and advisory service on matters that relate to pharmaceutics, pharmaceutical technology and the practical aspects of pharmacy. Areas of expertise include the application of physical, chemical and biological sciences to the formulation, design, stability, preparation and presentation of dosage forms. Enquiries about pharmaceutical packaging, especially child-resistant packaging, are also handled.

National Pharmacy Association information services

The National Pharmacy Association (NPA) has an information service for members only. The department is a complete reference centre, skilled at assisting members with a wide range of pharmacy practice-related questions such as drug information, NHS matters and law and ethics. It also publishes leaflets and resources on practice and legal issues, and community pharmacy-focused news updates. In addition, the NPA information department includes a specialist library of British and foreign reference books and a range of technical CD-ROMs. Further details can be found at http://www.npa.co.uk.

The pharmaceutical industry medical information departments

All pharmaceutical companies are able to provide certain types of information on their products. This source of information can be particularly important for new products, when there is often a lack of published information.