In a recent issue of Searcher [Eva Perkins, "Healthcare Resources on the Internet," Searcher, November/December 2000, vol. 8, no. 10, November-December 2000, pp. 53-57], I reviewed a core collection of print and online resources. This overview was followed by several key Web sites that have become widely used, the likes of which savvy searchers should learn to use for general purposes. This article will follow up with more specialized sites beginning with the most useful site of all, MEDLINEplus [http://www.nlm.nih.gov/medlineplus], a consumer-oriented version of MEDLINE. To illustrate the importance of MEDLINE, consider this: There has been an increase in MEDLINE queries from 7 million searches in 1997 to over 220 million per year and growing. It is estimated that one-third of MEDLINE searches today come from consumers, not to mention MEDLINEplus usage [Wood, Fred, "Public Library Consumer Health Information Pilot Project," Bulletin of the Medical Library Association, vol. 88, no. 4, October 2000, pp. 314-322].

Remember the big splash former-Vice President Al Gore made when he called a press conference in 1997 to publicize MEDLINE's availability on the Web — and at no cost? In fact, Gore conducted the first MEDLINEsearch on the Net at the press conference although I cannot tell you what he searched on (no jokes, please). Since then, public interest in MEDLINE has skyrocketed as people came to realize that they could use the authoritative source for medical, dental, nursing, and psychiatric literature. Since then, the National Library ofMedicine (NLM) launched the MEDLINEplus pilot project in 1998, designed to increase public awareness of, and access to, health information via the Internet. The pilot project involved 39 public library organizations with more than 200 locations in nine states (Alabama, Georgia, Maryland, New York, Pennsylvania, South Carolina, Tennessee, Texas, and Virginia) and the District of Columbia ["MEDLINEplus Press Release," Medical Library Group of Southern California and Arizona Newsletter, vol. 31, no. 2, January 1999, pp. 12-13].

Produced by the NLM, MEDLINEplus is a large, authoritative database of information on medicine, health, and wellness specifically designed for consumer use, as opposed to the original and more highly technical MEDLINE. Unlike the dot-com sites whose commercial nature may make some of their offered data suspect, this site delivers credible information in an easily navigated, user-friendly environment. It carries links to self-help groups, access to National Institutes of Health consumer health information, clearinghouses, health-related organizations, and clinical trial information.

Unlike the bibliographic abstracts of Medline, MEDLINEplus is a full-text database offering immediate usefulness. The directory feature of MEDLINEplus linking to organizations and other resources represents a key departure from MEDLINE, as is the inclusion of social issues such as divorce, addiction, and policy aspects. Clearly, MEDLINEplus focuses on a consumer audience. The largest body of information appears in the Health Topics section, with a huge collection of publications from such agencies as the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the National Institutes of Aging, of Cancer, of Mental Health, etc. Each topic entry offers an overview article plus related articles about symptoms, prognosis, treatment, and medication. Other articles focus on population subgroups such as women, children, teens, Native Americans, etc. At this time, Spanish is the only foreign language available, but other languages will be added in time. 

Besides the Health Topics, one can access the United States Pharmacopoeia, consumer edition, for drug information and the Health Illustrated Encyclopedia, which is licensed from Adam.com, a producer of online and CD-ROM health reference works. The United States Pharmacopoeia covers 9,000 prescription and nonprescription drugs searchable by brand or generic name. Entries are comprehensive and include dosage, contraindications, side effects, etc. Although the Health Illustrated Encyclopedia duplicates information provided elsewhere in the site, it has the advantages of numerous illustrations and short, readable entries. Users should find the links to Web resources such as doctors, hospitals, medical organizations and libraries, news sites, and medical research databases equally useful.

Information is arranged for browsing; queries are answered with a menu of choices: overview, treatment, symptoms, implications for special populations, etc. Searching is somewhat clumsy since one may only search the Health Topics section, with the United States Pharmacopoeia and Health Illustrated Encyclopedia, or in combination with the drug database. Thus, one cannot search the drug database or encyclopedia alone, or Health Topics and the encyclopedia. Apparently, some committee hit upon the set combinations as being the most useful, but are they? If one opts for searching the combinations available, one receives search results grouped by relevance ranking and not by source, which can be annoying. In addition to greater flexibility in cross-searching the three databases, user-friendliness could be improved by offering users a basic level of searching and an advanced level for Boolean operators, field searching, etc. At present, searching requires some decision-making about operators that must be off-putting to many folks out in the heartland. 

The designers of this incredibly valuable tool have redeemed themselves, however, by including a clear and simple link to MEDLINE from any Health Topic. MEDLINE, established by the National Library of Medicine to mirror Index Medicus in the early years of online databases, includes every article written in every important medical journal in the last 45 years. Once linked into MEDLINE, users can determine their appetite for the technical, sophisticated medical journal articles they will encounter and whether they want to try their luck at finding relevant articles. 
 

Pharmaceuticals
The Food and Drug Administration's Web site [http://www.fda.gov] is an excellent place to begin a search. Whether you need to know about the status of a drug's approval for sale, the availability of a generic version of a brand-name medication, or new reports of a drug's side effects, this site provides authoritative information. Designed for all comers, the site's home page features buttons for consumers or professionals. The consumer links lead to a smorgasbord of information — online articles only available on the Web, FDA pamphlets, congressional testimony, as well as useful, nongovernmental resources.

A prescription drug site that has proven helpful and trustworthy is the Pharmaceutical Information Network, or PharmInfoNet [http://www.pharminfo.com]. The site is one of many consumer sites operated by Mediconsult.com [http://www.mediconsult.com], reviewed favorably in the November-December 2000 issue of Searcher. Just as the commercial Laservision Center sponsors the Mediconsult.com eye care center, so a consortium of medical firms, including drug giants SmithKline-Beecham and Novartis, sponsor the Pharmaceutical Information Network. Indeed, the site provides information about sponsor products and links to these company' sites. Nonetheless, features such as Drug Infoline are good to know about; in fact, Drug Infoline is a handy complement to the FDA site. New medications are the focus here, including brand names, availability, manufacturer, intended use, how they work, and results from clinical trials. Drug DB lists hundreds of commonly used drugs (not necessarily new as in Drug Infoline). Basic information, news items, and plenty of outside links are available here. Searchable by disease, by brand name, or generic name, this site offers chat groups as well for hearing what others say about any given drug. 

We must post one caveat regarding the timeliness of information available from any healthcare, prescription drug, etc., site covered here. In my article published in the November-December 2000 issue of Searcher, I reported on a scandal unearthed by Dr. Janet Sybil Biermann and colleagues at the University of Michigan Medical School ["Evaluation of Cancer Information on the Internet," Cancer, vol. 86, no. 3, August 1, 1999, pp. 381-90]. To quote from my article, "Dr. Biermann and her colleagues had searched 371 sites for information about Ewing's sarcoma, a rare bone cancer that typically afflicts children and young adults. They discovered that half the online material was irrelevant and 6 percent contained major errors. In an interview with National Public Radio, Dr. Biermann described one such error that could devastate frightened parents. One site reported a survival rate of only 5 percent, when in fact the survival rate has improved a lot over the last several decades and survival rates of 75 percent to 80 percent are the norm!" In a similar vein, The Los Angeles Times reported recently that the Pharmaceutical Information Network site could be lax in updating vital medical information. In one instance, the site gave no inkling of the FDA warning about Lotronex, for irritable bowel syndrome, that can cause severe constipation and colon damage when TheTimes checked a month after the warning was issued [Benedict Carey, "Locating Timely Drug Information," Los Angeles Times, October 2, 2000, S, p. S2].
 

The E-Commerce of Health
Many Web health searchers will derive their information from commercial sites. Got an itch? Got a headache? Got a cold? Many people ask their druggist for suggestions. Now they ask online druggists.

Two commercial online "drugstores" have received a lot of attention — Drugstore.com [http://www.drugstore.com] and PlanetRx [http://www.planetrx.com]. Both sites are well established — and fiercely competitive with each other. Although only launched in January 1999, Drugstore.com has become a leader in the online drugstore market and hit the million-customer mark in February 2000, handily beating out competitors like PlanetRx. To achieve its preeminence, Drugstore.com blanketed the airways, Web portals, and morning talk shows with the virtues of buying vitamins and toiletries online. In time, however, online drugstores have begun to struggle with the same problems as other e-tailers on the Net — higher-than-anticipated start-up costs and too many players, leading to stiff price competition and the inevitable winnowing of the field.

Drugstore.com arrived first out of Seattle in early 1999 and enjoyed the backing of Amazon.com's Jeff Bezos (a 29 percent stake) and Kleiner Perkins Caufield & Byers, venture capitalists. More importantly, Drugstore.com became a click-and-mortar company when it signed an equity investment and partnership transaction with Rite Aid, a prescription drug retailer. PlanetRx debuted just 21 days after Drugstore.com opened its site for business. Although the two companies sprinted neck and neck through the chaotic business of getting operations off the ground, by the time PlanetRx pulled off its initial public offering (IPO) in October 2000, a mere 10 weeks behind Drugstore.com, it was already clear that it would lose the race.

According to reports in The Industry Standard, PlanetRx spent nearly $100 million on marketing and sales during a 1-year period ending in June 2000 while generating net revenues of only $26 million. Meanwhile, Drugstore.com struck a monster $105 million co-branding deal with equity partner Amazon.com at the beginning of 2000 — before the bottom fell out of e-commerce stocks. By that time, however, Drugstore.com's coffers were full, having raised some $200 million in financing, an amount it would supplement with a healthy $62 million private placement at the end of the summer. Although PlanetRx signed a 3-year agreement costing $15 million for the privilege of being the "premier online pharmacy partner" on AOL's Health and Women channels, and later cut merchandising and marketing agreements with Yahoo! and Women.com, the online pharmacy has not disclosed whether any of these deals paid off with more traffic or sales boosts [Karl Schoenberger, "Can Any Medicine Cure PlanetRx?" The Industry Standard, vol. 3, no. 38, September 18, 2000, pp. 154-170].

Begun as the dream of Michael Bruner, a former medical student, NetPharmacy (its original name) was launched in a low-rent apartment in Berkeley, California, to help patients enjoy the efficiency and ease of online commerce. In the spring of 1997, the renamed PlanetRx set up shop in a small office a few blocks away from Oakland's bay-front Jack London Square. In late 1998, PlanetRx progressed to the point of bringing in a big hitter as CEO, William Razzouk of FedEx fame. What worked at FedEx, however, definitely clashed with the laid-back culture of the California Internet start-up. CEO Razzouk's gruff, micro-managing style stymied the development of solid management decisions and sowed dissension in the ranks.

Besides lacking an offline drug chain partner and enduring management clashes, analysts have pegged PlanetRx' problems to its failure to negotiate an advantageous deal with the real power core of this sector, the pharmacy benefit-management industry. Prescriptions purchased with medical insurance dollars are overwhelmingly the majority of dollars in the industry, and benefit managers control the insurance contracts. By comparison, Drugstore.com's alliance with Rite Aid includes connections to its subsidiary, PCS Health Systems, which manages prescriptions for 50 million insurance beneficiaries. Within a week of Drugstore.com's IPO, PlanetRx announced its partnership with Express Scripts, the nation's third-largest pharmacy benefit manager, but the deal was rashly conceived and executed. PlanetRx had to pay almost $15 million annually in fees — more than its annual revenue at the time — for vaguely defined marketing services and the privilege of being Express Scripts' exclusive online pharmacy.

In any case, PlanetRx, like so many other Internet start-ups, placed its faith in an unstoppable Internet boom that would allow it to grow greater and greater revenues that would eventually lead to profits and eventually justify the exorbitant costs of hyping the brand. The Industry Standard published figures that indicate PlanetRx had net revenues of $18 million and net losses of $94 million in the first half of 2000, as compared to Drugstore.com's revenues of $47 million and losses of $104 million. A major retrenchment began in early 2000 at PlanetRx, with lay-offs that continued through the summer as well as relocation to its distribution center in Memphis, Tennessee. CEO Razzouk has gone and PlanetRx stock dropped below the dollar level by September 2000. By December 2000, PlanetRx was listed on a deathwatch among scores of e-tailers not expected to survive the Christmas shopping season [Charles Piller, "Like Garden.com, More E-Tailers Dying on the Vine, Los Angeles Times, December 7, 2000, A1, A36, A42]. 

Nonetheless, Michael Bruner's original concept of the Internet becoming an interactive tool that could do things like remind patients, particularly the chronically ill, to take their medication has proven to be well founded. Unlike "real" pharmacists, PlanetRx' virtual pharmacists send e-mail reminders to regular customers of its satellite sites, including Alzheimers.com, Breastcancer.com, Depression.com, and Diabetes.com, when prescriptions need refilling. Since the chronically ill are responsible for about half of all prescription drug sales, these relationships have kept PlanetRx afloat. 

This article will not cover the other click-and-mortar pharmacies, CVS.com and Walgreens.com, but at press-time both were alive and well.

PC Magazine featured Drugstore.com in a recent issue dealing with the challenge of finding and keeping online customers [Sarah L. Roberts-Witt, "Finders Keepers," vol. 19, issue 18, October 17, 2000, pp. 6-14]. Repeat customers spend more than first-timers or one-timers, and it costs more to acquire a new customer than to maintain the ones you have. Having attracted new customers by the droves, Drugstore.com uses technological gizmos of all stripes to get a complete picture of its customers and their behavior. A customer's click-stream is logged into a massive data warehouse running on Oracle8I, while proprietary software correlates this data with existing customer and marketing data. Reports on how many customers purchased a particular sale item, whether they clicked through from an ad, and which customers use online shopping lists help determine everything from where the next ads should be placed to what kind of e-mail newsletters should be created and to whom they should be sent. As elsewhere in the zany world of business-to-consumer and business-to-business Net economy, Drugstore.com is brokering partnerships that will bring even more shoppers into the fold. This past summer, Drugstore.com announced deals with national health insurance companies WellPoint and CIGNA Healthcare. Under these agreements, Drugstore.com will become the exclusive provider of online prescriptions for WellPoint's 22 million members and CIGNA's 25 million, as well as marketing special promotions and sales to those individuals.

How easy is it to order your vitamins and prescriptions drugs using Drugstore.com? Very. Taking a page from the Amazon.com model, both Drugstore.com and PlanetRx are easy to use and hassle-free. Bearing in mind that Amazon.com and Drugstore.com are business partners, it is not surprising to experience easy navigation, an enormous inventory at discount prices, excellent search capabilities, one-click purchasing, and an efficient delivery and return process. Visiting Drugstore.com, you find a home page that offers Medicine Cabinet, Nutrition and Wellness, and Pharmacy, plus others. Each has a clear hierarchy of choices, easy-to-use Buy buttons, May We Suggest buttons, a shopping cart, and all the proper disclaimers. For instance, clicking on the question, "Why should I entrust my prescriptions to you?" leads users to a statement verifying that Drugstore.com is a VIPPS site. The statement says, "The National Association of Boards of Pharmacy recognizes Drugstore.com as a Verified Internet Pharmacy Practice Site (VIPPS). The VIPPS seal assures you that our pharmacy services meet the highest possible standards for Internet pharmacies. Drugstore.com was a leader in helping establish these credentials. Learn more about VIPPS cerification [sic]."

Another disclaimer offered on Drugstore.com's home page reads, "Information on this site is provided for informational purposes and is not meant to substitute for the advice provided by your own physician or other medical professional. You should not use the information contained herein for diagnosing or treating a health problem or disease, or prescribing any medication. You should read carefully all product packaging. If you have or suspect that you have a medical problem, promptly contact your healthcare provider. Information and statements regarding dietary supplements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any disease." 

Whether you choose Medicine Cabinet, Nutrition and Wellness, or Pharmacy, you are led into a series of pages with a "Directory" listing of more specific options as you progress. Medicine Cabinet leads to a directory of common complaints such as digestion, cough and cold, allergy and sinus, pain and fever, etc. One item in the list was Medical Equipment, and that leads to another directory of choices, including independent living and bath safety products. At this point, you begin to notice prominently displayed brand names available for purchase. For instance, all the bath safety items and independent living products are manufactured by Rubbermaid. Sunbeam is the manufacturer du jour when looking for heating pads. When we checked eye and ear care, however, we found buttons for three major brand names — Ciba, Opti-Free, and Bausch & Lomb. By the way, the directory for eye and ear care includes logical choices such as redness and allergy drops, artificial tears, eye ointments, etc. Moving on to Nutrition and Wellness, the directory choices are diet aids, homeopathy, and nutritional supplements, among others. Narrower terms under diet aids are scales, shakes and powders, weight loss supplements, etc. 

But can you search directly to scales? Yes, but the keyword search option may have a catch! Searching on "scales" in the Medicine Cabinet section yielded only three scales priced from $39.99 to $149.99, while the Nutrition and Wellness section yielded nine scales priced from $39.99 to $2,999.99. Maybe Drugstore.com needs to hire a few librarian/taxonomists? You think?

A nice feature of the Pharmacy section is Ask Your Pharmacist. Typing in keywords results in canned FAQ-type responses. For instance, the keyword "earache" retrieves two options that you can click on for the answer, "I think my child has an ear infection. What should I do?" and "What is the difference between a cold and the flu?"

Once you have filled your shopping cart, you are led through the usual information about payment, shipping, and price choices. Data about these transactions is transferred to the personalized features of Drugstore.com. The next time you log on, you may click on Your Account, Your Prescriptions, or Your List and short-circuit some of the click-stream you went through initially. PlanetRx is arranged very similarly in terms of these personalized links to your own history. Also, both sites have message boards.

Once you begin to shop at drugstore sites, be sure to look for the Verified Internet Pharmacy Practice Sites, or VIPPS. In 1999, the National Association of Boards of Pharmacy (NABP) created a program called Verified Internet Pharmacy Practice Sites [http://www.nabp.net/vipps/intro.asp] that gives consumers a single place to check out an online pharmacy to ensure that it meets current standards. To receive VIPPS certification, an online pharmacy must meet the licensing and inspection requirements in the state where it is located and each state to which it dispenses pharmaceuticals. In addition, VIPPS online pharmacies must protect a patient's right to privacy, ensure authentication and security of prescription orders, adhere to a recognized quality assurance policy, and provide a mechanism by which patients can get their questions answered by a pharmacist. At this time, the FDA is working with the NABP to protect consumers from unscrupulous Internet sites selling prescription pharmaceuticals.

Only a handful of online drugstores in addition to Drugstore.com and PlanetRx carry the VIPPS seal of approval. Caremark, Inc. [http://www.rxrequest.com], Clickpharmacy [http://www.clickpharmacy.com], eMed.com [http://www.emed.com], and Tel-Drug, Inc. [http://www.teldrug.com] are some of the more familiar. Not all offer the same features, however. Caremark, Inc. is limited to filling prescriptions. The site is very streamlined, no bells and whistles, and certainly no drugstore stock such as bathroom scales. Clickpharmacy offers an Ask Your Pharmacist feature that links to an e-mail window in contrast to the FAQs at Drugstore.com. So, depending on the credentials, knowledge, and literacy of the individuals responding to the e-mail, you might be better off going to Clickpharmacy for this service. On the other hand, Clickpharmacy has one real disadvantage. When you click on the Consumer link from the front page, you get a difficult to read, very small window, so small that you need to scroll on each line to completely read a sentence. Overall, Clickpharmacy is not as grand or user friendly as other sites.
 

Till We Meet Again
So, what's it all about, Alfie? In this reporter's opinion, the exciting, marvelous aspect of online pharmacies is that they take the power of interactivity via the Web and run with it. Chronically ill people are e-mailed reminders to refill their prescriptions and even to take their medication! Virtual pharmacists are available to answer questions, some 24/7. Consumers can look up adverse effects at their leisure and in the privacy of their homes. And information professionals can mine the wealth of pharmaceutical knowledge as never before. 

Long live the Web!