The present study shows that a large majority of Italian pediatricians frequently use the Internet during their practice for supporting their clinical decisions, and are willing to use tools and platforms that favour the interaction with families. The rate of Internet use during consultation detected in our survey parallels that indicated in an European study performed among Italian general practitioners in 2008 [14
]. Moreover, our results are in line with those provided by other studies on the use of the Internet during clinical practice by other medical profiles and in other settings [19
Bibliographic resources are among those that medical professionals search most frequently online [21
]. The finding that pediatricians search more frequently through Medline and Cochrane is consistent with the results of a previous study performed among general practitioners in Switzerland [22
]. Although we did not investigate whether pediatricians preferred to consult open access journals, respondents in our sample clearly expressed the willingness to have a wider access to bibliographic resources. The scientific information need may not be completely satisfied by existing resources. A stronger effort should be put by the scientific community in providing open access resources to physicians.
Access to information on the Internet relevant to clinical practice may however be affected by English skills since a large part of scientific information on the web is provided in this language. Although online translation services have become popular tools, translation in local language of scientific documents, including clinical guidelines, may improve accessibility to their content.
More than 70% of interviewed pediatricians search for clinical guidelines or drug references during their practice, while information concerning diagnosis is searched less frequently. This observation may be relevant to the format in which information is presented on the Internet. In fact, most documents on the Internet are available as plain text, sometimes too long or too complex to be easily managed during practice. Evidence-based information should be presented on the Internet through formats that improve accessibility and readability, provided in conjunction with traditional documents, if they are to be effectively used by clinicians.
We did not investigate how pediatricians seek information for diagnosis. It is possible that diagnostic features are searched online through generic search engines [23
]. Although this approach may be helpful, a wider access to clinical decision support systems is desirable and a significant proportion of respondents expressed the willingness to access such systems.
Thirty-two percent of respondents stated they access the Internet through a Smartphone. Italy is one of the countries with the highest Smartphone penetration in the world, with nearly 38% of total users in 2011 [24
]. The large use of Smartphones represents an opportunity for improving access to clinically relevant information on the web. At present, medical Smartphone applications are mostly available in English. Availability of this kind of applications in local language is likely to improve access to scientific information useful for clinical practice.
A significant proportion of respondents in our study as well as in other studies [21
] is interested in collecting from the Internet medical information material for families. Moreover, the results of our study show that information material for families, secure communication systems with families, personal health records, and social platforms are desirable web resources for pediatricians. This observation confirms the interest of pediatricians for tools that support continuity of care [9
Our results indicate a more frequent use of the Internet during clinical practice by younger pediatricians, males, and those living in Northern and Central Italy, These results are in line with the factors affecting the use of the Internet in the general population according to a National survey [18
]. Our results also show a less frequent use of the Internet by family pediatricians, in agreement with the assumption that they deal with less complex clinical problems compared with specialists.
We found that younger pediatricians are more likely to be influenced in their clinical decisions by information found on the web. A possible explanation for this finding could be that older and therefore more experienced pediatricians might feel less need of a decision support system compared to younger pediatricians.
Hospital pediatricians and other pediatric profiles such as those working in private practices or local health units were also more likely to be influenced by information found online compared with family pediatricians. This observation may be linked to the greater clinical complexity of children usually seen in hospitals or in private practice as compared with primary care.
A low proportion of respondents stated that social networks may be useful for their clinical practice. We did not investigate the reasons underlying these results, however we may hypothesize that respondents were possibly concerned about privacy and confidentiality issues, as addressed in the policy statement on professionalism in the use of social media by the American Medical Association [12
Interestingly, male respondents were more likely to use the Internet during clinical practice and to consider social networks potentially useful in clinical practice.
We could hypothesize that this is in line with a more frequent use of the Internet by males, as reported by the National Institute for Statistics [18
]. Though, this result is not found in the other models. Nevertheless, this issue will deserve attention in future studies, since it might be associated with personal use of social networks in private life.
On the other hand, nearly half of respondents considered personal health records potentially useful for their practice. Registrars and hospital pediatricians, irrespective of their age, considered that integrating clinical records with information provided by the family may be useful for clinical practice. While registrars may be more oriented to new opportunities for data collection from patients and their families, hospital pediatricians, who mostly have occasional contacts with patients, may consider personal health records as a useful tool for a comprehensive view of the patients' history.
Our survey suggests that Italian pediatricians favour the use of social networks and of other tools for communicating with families. This finding seems in contrast with other studies that show that physicians are quite sceptical about the potential benefits provided by patient-physician communication [19
]. The opinion on the usefulness of web-based tools for communication with families may depend on the perception of a potential for an easier disease management, especially regarding chronic diseases, as suggested by another study [26
]. Interestingly, the use of these tools during clinical practice, although endorsed by the American Academy of Pediatrics, poses implementation challenges regarding confidentiality, integrity, and availability of patients' data [27
Limitations of the study
Our study has several limitations. There might have been a strong selection bias: although an invitation to join the survey has been published on the paper issue of the Society's news magazine, which is received by all the Society's members, the email invitation, sent only to those members that had provided an email address, may have selected those who are more accustomed to the use of the Internet and who likely check their mail on a regular basis. This may have overestimated results in all the items related to the use of the Internet. Nonetheless, age and sex distribution of respondents only slightly differed from that of the general pediatric community.
Participation was on a voluntary base, and therefore participants may not represent the general population of Italian pediatricians and may be selected among those with a stronger interest toward the web. This may have reflected on the proportions of pediatricians using the Internet during clinical practice and favouring social network and personal health records, that may have been overestimated.
Moreover, this is a cross-sectional study, and no previous figures are available in order to measure a time trend.
On the other hand our survey had a high quality of responses due to the limited time requested for filling in questionnaire, with a resulting low missing value rate. Moreover, despite limitations, the study may serve as a term of comparison for future cross sectional studies on the same subject and for comparison with other health settings.