E-book Revolution Changes, Challenges Healthcare

If you've flown lately, you've seen them everywhere: e-books, running on Kindles, on iPads, on any number of tablet devices. Get ready to see them a lot in healthcare too.

Prompted by an announcement that yet another standard desk reference had been released in e-book form, I wonder if we've reached a tipping point yet where the standard nurse or doctor's desk reference on paper has gone the way of the telephone book.  I normally recycle these phone company dinosaurs as soon as they land on my doorstep.

Think of the upside. E-books are fully indexed. Any occurrence of a word is searchable with a touch. Paper-based indexing systems just can't compete.

Publishers can update e-books as often as necessary. Paper-based desk reference books are still updated at least (and often, at most) once a year.

But e-books aren't free. In fact, according to one medical librarian I talked with recently, they can cost more per copy than the individual paper editions of the same book, particularly when purchased by an institution and not by an individual.

Healthcare costs are already skyrocketing, so the last thing medical libraries need is a huge increase in the cost of acquiring the books and journals they require to keep clinicians well-informed.

Some medical libraries rely heavily on their version of the interlibrary loan program one finds at many public libraries. When the book in question is an e-book, however, that medical library has to negotiate successfully with the e-book publisher to permit interlibrary loans, which often take the form of producing a PDF of a particular journal article or chapter and providing just that PDF to the requesting medical library.

Some e-book publishers are having none of that, however, prohibiting interlibrary loans of their e-book titles. So the great benefits of e-books end up begin matched by the aggravating complexities of license agreements and digital restriction management. (Don't call it digital rights management.)

It came as a mild surprise to the medical librarian in question, Michelle Kraft of the Cleveland Clinic, that the new e-book that I'd learned of was being offered at the same price as the paper equivalent.

Kraft is a thought leader in this area, having presented to the Medical Library Association in 2010 on e-books. Kraft evaluates and implements online resources for use within the Cleveland Clinic health care system.

"That tipping point I don't think is going to happen tomorrow," Kraft says. "I think we're in the process of tipping. It's a long process."

The past four years have seen another tipping point of sorts at the Cleveland Clinic medical library. Four years ago, it had 800 subscriptions to print journals. Today, that number is down to eight. I had to ask Kraft to repeat that number to be sure I had heard her correctly.

Of course those journals are still available at Cleveland Clinic, only now they're electronic edition. But typically, access is via a Web browser. And with journals in particular, the notion of an interlibrary loan can go away once it's in electronic form.

I've seen journals that are accessible only within the computer networks of a particular university, for example, but not from the larger Internet, due to licensing restrictions.

Then there's the lag that many journals have in reaching the platform of choice: the e-book. Many electronic copies of journals are still browser-based, not e-book based, Kraft says.

Cost is a big concern for medical libraries. Cleveland Clinic's library budget is basically held flat, with increases for inflation and for "explainable increases" in subscription rates, Kraft says. Moving from a book to an e-book can be one of those explainable increases.

When the publisher Lipincott approached me to tout its new e-book version of The Nursing Drug Handbook, I got a chance to speak to the publisher's chief nurse, Judith McCann MSN RN. I suggested to her that the current shortage of nurses and doctors suggests it's time for a revolution in the education of nurses and doctors in training. Could e-books be it?

"The amount of information [nurses and doctors] have to absorb today is phenomenal," McCann says. "The books themselves have probably quadrupled in size in the last 25 years."

So if nothing else, toting around the e-book version on a tablet is a lot less effort physically. Add to that the fact that the drug interactions in the new Lipincott book get updated weekly, based on new data from the FDA, and then add in the easy search and other e-book features, and it's hard to make a case for staying with paper.

Demand for even the paper drug references is such that nurses and doctors who don't get copies issued by their institutions often end up beyond them and paying for them out of pocket. That could be a considerable extra cost, so hospitals should defray or underwrite this cost as a component of keeping employee satisfaction high.

Some reading this might counter that electronic medical records come with their own drug interaction database. I asked McCann about this.

"A lot of those EMR drug interaction systems are pharmacy-based," she says. "We use nursing considerations. For example, one adverse reaction to a drug might be dry mouth. We say remember to encourage the patient to drink or do something to alleviate the dry mouth. That's nursing care as opposed to medical care. We turn it into the nursing actions that are related to that particular drug."

The e-book is only going to grow in importance in healthcare. Consider the ability on many e-book platforms for the reader to easily highlight material. Now add a social element. On the Kindle, e-books I've read can display highlighted passages as gleaned from other readers of the same book. It's another great way to learn and keep current.

Let's just hope in the rush to electronic medical records that e-books remain affordable and accessible. Let's hope some of what made traditional medical libraries great, such as interlibrary loans, remains a part of the solution.

The transition away from print journals from great institutions such as Cleveland Clinic is bound to impact smaller medical libraries that can't afford their own medical journal subscriptions and have relied on interlibrary loans.

McCann told me one other poignant story. It seems that back in her hospital days, some of the paper references had a habit of walking off. So nurses drilled a hole up in the corner of the book. "We took a chain and attached it to the drug cart," she says.

That's testimony to the power of information in healthcare, and the lengths to which staff will go to have access to it. In the brave new world of e-books, we have to preserve and expand that access.