CHAPTER 2

Focus and Key Points of Physician On-Line Reference Guide

Focus of this Physician On-Line Reference Guide:
This physician on-line reference guide has been prepared with the intent of providing current and accurate educational information in a "user friendly" format for clinicians. Although there are valuable resources available to assist physicians with the diagnosis and management of waterborne disease and the health effects of water pollution on the Internet, several recent studies indicate that this information may not be frequently accessed by busy practicing physicians:

• A review of health information on the Internet revealed that even if online medical resource materials and patient educational materials are comprehensive and accurate, the ability of the user to access and utilize this information depends upon their ability to locate these resources on the Internet (1).
  
  
• Even if physicians are not readily accessing medical information from the Internet, their patients are using the worldwide web to search for health information in record numbers. One recent survey of 900 outpatients indicated that more than two-thirds of them plan to use the Internet as a source for medical information in the future (2).

There is a wealth of general and detailed information regarding various aspects of water-related disease and water contaminant exposure available on the Internet. This information includes a full spectrum of resources from clinical practice guidelines to patient fact sheets to results of ongoing research. However, locating this information is often difficult for most health care practitioners with limited time during a typical patient visit. In order to facilitate easy access to useful Website information for the busy practicing clinician, we have organized and categorized this specialized information in a manner that incorporates: 1) ease of access for practicing physicians and 2) offers technology support for the physician user at every feasible opportunity.

Unique Features of this Physician On-Line Reference Guide:
The primary purpose and educational intent of this Physician On-Line Reference Guide is to address the critical need for practicing physicians to have access to peer-reviewed educational resources to assist them in the recognition, management and prevention of waterborne disease and the health effects of water pollution resulting from natural, accidental or intentional contamination of water reserves. Maintaining water quality and securing the safety of water supplies in the United States requires participation from the medical community.

The importance of this participation has been underscored by the growing threat to the security of our nation's infrastructure that includes the possibility of intentional contamination of US water reserves by covert terrorism. Practicing physicians are likely to be the first to observe unusual illness patterns or disease trends resulting from intentional biological, chemical or radiologic contamination of water supplies and must understand their critical role in detecting water-related disease and in cooperating with water utilities to protect their community's public health.

This Physician On-Line Reference Guide has been launched to assist healthcare providers recognize and manage waterborne disease and the health effects of water pollution resulting from either natural OR intentional contamination of water. Unique features of this Physician On-Line Reference Guide include:

• "24/7" availability with free access to 366 webpages of comprehensive information
• Clinically relevant information detailing detection and management of water-related disease from both waterborne pathogen and chemical contaminant exposure
• Repository of physician anti-terrorism preparedness and readiness resources (please click here to review Physician Preparedness for Acts of Water Terrorism)
• Special risk communication and patient risk evaluation guidelines for both healthy and susceptible populations regarding water-related disease
• "Ease of use" technology tools and website support for busy physician users
• Targeted search engines providing quick and easy access to 200 websites covering a diverse array of waterborne disease and water contamination issues
• Peer-reviewed content by leading medical and public health experts from medical academia and public health agencies including CDC, ATSDR, and EPA
• CME accreditation for credits toward AMA Physician's Recognition Award
  

Clinician Internet Resource Guide and Search Engines:
Accessing environmental health information using general Internet search engines and broad search terms is often inefficient, time consuming and impractical for most practicing healthcare providers. During the development of this Website, we reviewed hundreds of environmental health and water-related Internet sites hosted by a large pool of governmental, private, academic and professional organizations. We have organized these valuable Internet resources for targeted use by healthcare providers in the following manner:

• We have summarized over 200 Websites for your review that we believe provide both useful and accessible information relating to various aspects of waterborne disease and water pollution.
  
  
• We have developed several technology tools to assist you including a series of general and targeted search engines. These tools allow quick and easy access to valuable information available on the Internet and have been incorporated throughout this guide.

Whenever possible during our Website review process, we attempted to incorporate the guidelines set forth by the American Medical Association and the American College of Preventive Medicine addressing medical and health information presented on the Internet. In addition, we followed the quality standards and code of conduct developed by the nonprofit organization, Health on the Net Foundation (HON). We refer to these selected websites throughout every chapter of this guide. In addition, we have summarized these resources and dedicated an entire chapter to their review, which serves as the most powerful informational tool in this guide (To view Chapter 10: Clinician Internet Resource Guide and Search Engine, click here).

Key Points of this Physician On-line Reference Guide:
This reference guide provides access to clinically relevant information and specialized educational resources for practicing physicians in several major areas of increasing importance and growing concern among those responsible for protecting public health and water safety:

Basics of Water Safety and Protection: In order for healthcare providers to accurately diagnose waterborne disease and provide appropriate risk communication information to their patients regarding water quality and safety, they must have a working knowledge of the basic parameters of water protection and water pollution. We have included a discussion of the types of waterborne outbreaks by water source, the causes of water pollution, and the mechanisms of exposure to water contaminants in this guide. This understanding is crucial in order for healthcare providers: 1) to counsel their patients more appropriately regarding their personal risk profile and risk reduction behaviors to prevent the development of water related disease and 2) to complete more comprehensive and accurate exposure histories when patients present with symptomatology consistent with waterborne disease (3).

Evaluation and Management of Disease Resulting from Waterborne Pathogens: A synopsis of the sources of exposure, routes of transmission, symptomatology, and clinical management guidelines for the most common infectious waterborne pathogens encountered in the U.S. is highlighted in this physician guide. In addition, the appropriate use of diagnostic laboratory testing and the need for standardization of laboratory detection and analysis in local community medical centers in order to prevent costly pseudo-outbreaks is presented. The mechanisms for reporting suspected waterborne diseases to public health authorities and the role that local water utility practitioners play in water protection efforts such as ongoing monitoring of infectious pathogens in water reserves is also addressed in this reference guide.

Evaluation and Management of Disease Resulting from Chemical Contaminants: An overview of major water pollutants and associated health effects including: 1) inorganic chemicals, 2) organic chemicals, 3) disinfectants and disinfection by-products, 4) radionuclides is included in this physician reference guide. Specific references to "hot issues" such as chlorination byproducts and endocrine disrupters are also included. In light of the extensive number of chemical contaminants that may be present in water if accidentally contaminated, a standardized protocol that "walks" the physician through the appropriate evaluation of potential chemical contaminant exposure using valuable Internet resources is presented. A review of informational resources and databases accessible to the busy clinician has been incorporated including Internet resources available through governmental, private, academic and professional organizations that focus on chemical contaminants.

Evaluation and Management of Water-related Disease in Susceptible Populations and Risk Communication: Another element of this physician on-line reference guide examines the special health needs of sensitive populations at greatest risk for morbidity and mortality from exposure to waterborne contaminants including the presentation of state-of-the-art health advisory guidelines. Identification of these "at risk" groups has been underscored with focused emphasis on immunosuppressed and immunocompromised patients, pregnant women and developing fetuses, infants and children. A specific discussion of the relative risk associated with waterborne contaminants for the general population and susceptible populations in comparison to other risk factors in their environment and lifestyle has been presented. A review of risk communication and patient education materials and techniques that are appropriate in a clinical setting have been incorporated as well.

Free Access to Physician On-line Reference Guide:
We trust that you will find this Physician On-line Reference Guide a valuable informational resource as you approach the many aspects of addressing the recognition and management of waterborne disease and the health effects of water pollution. Access to this On-line Physician Reference Guide is provided to health care practitioners at no cost. This resource has been funded by the Environmental Protection Agency, American Water Works Association and the Arnot Ogden Medical Center. In order to obtain free access to the remainder of this Website please click here to sign in.

Continuing Medical Education (CME) Offering for Physician On-Line Reference Guide:
The American College of Preventive Medicine (ACPM) and Dr. Patricia L. Meinhardt, a representative of ACPM, have developed a Continuing Medical Education (CME) module of this Physician On-Line Reference Guide. This Continuing Medical Education (CME) online resource is intended to provide healthcare professionals with an educational experience that will 1) improve their diagnostic acumen in the recognition, treatment and prevention of waterborne disease and the health effects of acute and chronic exposure to water pollution; 2) increase their working knowledge of waterborne disease surveillance and exposure pathways and 3) enhance their risk communication skills and strategies when providing information to their patients regarding water quality and safety in their clinical practice.

The American College of Preventive Medicine (ACPM) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide CME credits for physicians participating in this continuing medical educational activity. Through ACPM, Category 1 credits toward the American Medical Association (AMA) Physician's Recognition Award (PRA) are offered. ACPM will award a Continuing Medical Education (CME) Certificate to physicians (MDs, DOs) completing this educational activity and a Certificate of Participation to non-physicians participating in this continuing education.

This CME online course is organized into 10 chapters that represent the chapters of the Physician Online Reference Guide that have been included in this CME online offering. These chapters represent a comprehensive core curriculum of clinically relevant information and specialized educational resources for practicing physicians in several major areas of increasing importance and growing concern among those responsible for protecting public health and water safety. The ACPM designates this educational activity for a maximum of 22 hours in Category 1 credits toward the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he or she actually spent in this educational activity. CME credit can be earned for the entire course OR for individual chapters of Recognizing Waterborne Disease and the Health Effects of Water Pollution: A Physician Online Reference Guide.

To review information regarding this CME offering, please click here to sign in.

References:
Selected references are available in full text by clicking on the highlighted text below.

1. Berland GK, Elliot MN, Morales, LS, et. al. Health information on the Internet: accessibility, quality and readability in English and Spanish. Journal of American Medical Association 2001;285:2612-2621.
2. O'Connor JB, Johanson JF. Use of the web for medical information by a gastroenterology clinic population. Journal of American Medical Association 2000;284:1962-1964.
3. EPA, National Drinking Water Advisory Council-Health Care Provider Outreach and Education Working Group: Draft Report. October, 1999.
   

Patricia L. Meinhardt, MD, MPH, MA, Author

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