With advances in technology, easier accessibility and decreased costs, the internet has become a popular tool for learning. It has been reported by the Office of National Statistics that approximately 77% of the United Kingdom (UK) population in 2011 has access to the internet (web) [1]. Prior studies have suggested that e-learning (in this report it refers only to computer based learning) is an effective learning tool [2-5]. It has been used in medical education but there is no robust evidence to support its use by health professionals for their own or their patient’s education within the musculoskeletal professions and specifically in Rheumatology.

Patient education plays a vital role in the health care of patients (especially for chronic diseases) and has been widely used [6-9]. It has been shown to improve their understanding about the disease process and its management leading to improvements in clinical outcome and self-efficacy. A recent systematic review outlined the positive effects (clinical and psychological) of patient education on Rheumatoid Arthritis patients [9]. In this review apart from the improvement in disease-related knowledge, outcomes and the psychological advantage, it was reported that the use of patient education has been associated with improvements in self-management as well as a decrease in health costs.

E-learning as a means of educating patients is relatively new with a relatively low utilisation by health professionals. It was reported by a study in the United States (US) that 40-50% of the US population in 2003 obtained health information online and almost 50% of these individuals preferred searching the web first while only 10.9% went to the physician first [10]. A different report found that only 3% of patients received a doctor’s advice to seek health information on the internet while 62% agreed that they should be guided by their doctor [11]. The low use of the internet for obtaining health information was linked to the variability in quality of information found on the internet. A patient based survey explored how participants used the internet for health information [12]. The population comprised adults older than 18 years attending outpatient clinics during a two week period in a major city (Nottingham) in the UK. They found that 63% of the study subjects (sample of 663) had access to the internet while 42% had used the internet to obtain health information in the past. Almost all of the subjects in this study who had used the internet felt that the information they obtained was above average while four out of five subjects reported that they would like to access trustworthy information.

Musculoskeletal healthcare involves dealing with chronic disease in which education is an important aspect of care and it is therefore of great interest to study how it is affected by e-learning. Reports in the past from a health professional perspective have shown benefits for the use of computer based learning in patient education and healthcare [13, 14]. There are no previous reports studying the use of computer based learning specifically in musculoskeletal healthcare from the medical professionals’ perspective. This study addressed this issue and furthermore made an assessment of currently available patient and professional educational web resources in this field.

A survey devised by a group of healthcare professionals with input from various Rheumatology and Orthopaedic organisations (British Society for Rheumatology (BSR), Arthritis Research UK (ARUK), British Health Professionals in Rheumatology, Primary Care Rheumatology, British Orthopaedic Association and trainees, including the Rheumatologists at Training & British Orthopaedic Trainees Association) was placed on an easily accessed website (surveymonkey.com). A link to the survey was placed in the BSR E-newsletter of 14 September 2010. Where feasible, reminders were sent electronically, either to the same mailing list, or by cascading emails through regional administrative leads. The survey ended on the 8^th of November 2010.

Participants were anonymous and the survey consisted of 16 questions relevant to health professionals’ educational practice and personal characteristics (Table 1). No confidential information pertaining to patients was requested. Two of the questions required rating of a number of websites listed by the British Society of Rheumatology for education purposes (for both health professionals and patients). Questionnaire responders had the option to suggest unlisted websites along with a rating. A Likert rating system (0=worst to 5=best) was used for rating the websites. The complete questionnaire can be accessed via “http://www.surveymonkey.com/s/BSR-Arthritis_Research_UK_National_E-Learning_Survey”

Statistical analyses were performed using Microsoft Excel, 2003. The chi-square statistic or two sample t-test were used for all comparisons. 95% Confidence Intervals (CI) about the mean were calculated for the website ratings. An alpha value of 0.05 was chosen for significance purposes.

192 individuals had completed the survey. Two were excluded because they reported a profession other than healthcare. The characteristics of the responders are presented in Table 2. Individuals from at least twelve health professions relating to musculoskeletal care responded. There was almost equal representation of male and females and the majority were 50 years of age or younger. A higher proportion of females were noted in the younger age groups. 124 of the responders were within the Rheumatology profession

This survey has shown that almost all musculoskeletal health professionals responding to an email invitation and completing an online survey use the computer for their own education purposes (both at home and at work). There is high use (>67%) of mandatory training online, CPD and completion of online modules. Females spent more time using computer-based education while younger responders tended to use the computer to a greater extent. This is consistent with existing literature indicating that older individuals use computers less (including those for obtaining health information) [15]. The preferred format for e-learning was interactive online content.

Although the web is used increasingly to obtain health information (greater than 50% of individuals that search the web seek health information) [16, 17], this study has shown that only 40% of musculoskeletal health professionals reported that their patients obtain health education via the web. This percentage although being the view of the musculoskeletal health professionals (which may not match the actual usage of the web by their patients) is below expectation. Patients may use the internet to obtain health information even though it is not an education method used by their health care professional (in which case their health care professional may or may not be aware) or they may not use the web to obtain health related information even though they have been advised to do so. It is though comparative to prior studies from a patient perspective who have reported percentages ranging from 20% – 50% [13, 18, 19]. In a doctor based survey completed in the UK in 2001 with a majority of General Practitioners found that only 1%-2% of their patients had used the internet to obtain health information in the month prior to the study [14]. Demographic location based on the subdivision of North and South of the UK revealed no difference in computer based patient education. No further stratifications in location were attempted due to small sample size. Insufficient resources for education groups, poor computer access and reading and writing difficulties were perceived to be the most common obstacles to patient education. No gender differences were noted among those that use the web versus those that don’t use the web for patient education. The degree of computer use was not associated with the use of web-related material for patient education. There were several characteristics (questionnaire responses) of the participants that may be associated (although not statistically significant in this sample) with the use of the web in their patient education practices (CPD, barriers to education such as ‘Insufficient resources for education groups’, ‘lack of perceived need’ and ‘reading and writing difficulties’).

This survey also showed differences in education practices among the Rheumatology professionals and other professionals within the musculoskeletal field. A larger percentage of Rheumatologists used online education, mandatory training at their trust and continuing professional education (although this may partly be accounted for by the small number of study subjects from the other professional groups and also that the Rheumatologist groups were of a younger age). Nevertheless, this finding may need to be investigated further in a larger and more representative sample.

One of the greatest concerns about using computers and the web for patient education has been the variable quality of information [20-23]. Some have suggested using a validation system in grading the websites available. This is challenging in that there is a continuously expanding number of websites and also that medical information changes so rapidly that the information would need to be validated at least every few months. It was shown by this survey that musculoskeletal health professionals have rated most website resources listed on the survey as above average with a few obtaining excellent scores (UpToDate and Arthritis Research UK). More than half of the websites attained a score above 3 (best=5).

This is the first national survey of the use of computers in the education of musculoskeletal health professionals and how they utilise learning resources for their patients. As this is the current practice of musculoskeletal health professionals the results should be compared with patients’ responses to questions about e-learning so that provision of material will have the best chance of meeting patients’ needs. Furthermore it gives an assessment of current web resources that can be utilised for patient education, recommended by health professionals. The questionnaire used in this survey was newly devised by a multidisciplinary team of musculoskeletal health professionals (with good content validity). It was not possible to calculate the exact response rate since the survey was open to everyone (excluding the 45 trainee Rheumatologists the responses obtained represent approximately a 12% response rate. The gender (male to female ratio of 2 to 1) and age distribution (Royal College of Physicians vs survey participants: <40, 16% vs 13%; 40-50, 44% vs 35%; 50-60, 29% vs 38% and >60, 11% vs 11%) of the study sample was representative of the study population as cited by the Royal College of Physicians census of 2009) [24]. There was evidence of over-representation of younger health professionals. This is not unexpected given that younger individuals tend to use the computer more in general and thus were more likely to participate in the survey. Given that this questionnaire was administered online there is the possibility of selection bias as health professionals that use the web more would be more likely to complete it. This would tend to overestimate the percentage of computer based education for both professional and patients. There are also potential issues for generalizability since our sample was based in the musculoskeletal field and mainly consisted of Rheumatology physicians (65%) and should thus be interpreted primarily within that population. Furthermore the sample size may not have been large enough in order to detect differences in responses especially when stratifications were made.

Results from this survey suggest that targeting e-learning characteristics may offer ways to improve patient education with the use of e-learning. For example making CPD with a diary portfolio more readily available and necessary in health professionals may increase the number that use or adjunct their patient education with the use of web resources. The barriers also need to be resolved to allow the education process to evolve. This would involve educating patients and health professionals on the advantages of e-learning, making computers more accessible, creating sustainable venues that are convenient for patients to use and utilizing different methods to overcome reading and writing difficulties, such as involving family members, friends or using study groups. Health professionals that use the web for patient education rated a greater number of websites suggesting that there should be a greater effort in educating musculoskeletal health professionals about the available quality website resources and thus establishing the web as part of their patient education. These web ratings should be used as a guide to where to search for quality information but should always be tailored to the patient needs and abilities and should always be correlated with the health professional’s recommendations. Newly developed web resources should include interactive online content as a mode of web based learning but not limited in order to appeal to a wider group.

With more reliable web resources for patient education and new evidence supporting the use of e-learning in patient education it is suggested that e-learning becomes an integral part of patient education. It is thus important that health professionals understand and support its use and find ways to include it in their patient education plans. New research should be formulated to study the implementation of the web in patient education using the most appropriate methods (i.e. experimental studies). This requires a greater understanding of the patients learning practices and abilities (including social, environmental and educational factors) and taking into account the limitations relating to their illness. This may mean that future research should be disease specific as well as patient specific.

Almost all musculoskeletal health professionals use electronic learning resources. In this sample a gender effect was observed with a higher proportion of females utilising computer based learning for longer periods. Interactive online learning was the preferred format for computer based learning. The use of e-learning in patient education by musculoskeletal health professionals remains low even though a larger percentage of adults are accessing information on the web. Insufficient resources for education groups was the most commonly referred barrier to educating patients while literacy remains a significant barrier. There are highly rated educational web resources available for both professionals and patients.