SETTING YOUR “SITES” ON EFFECTIVEINFORMATION MANAGEMENT

Lynn Dunikowski & Mike Dillon51st Annual Scientific Assembly

Manitoba College of Family PhysiciansApril 20 – May 2, 2009

Haynes RB et al. How to keep up with the medical literature: V. Access by personal computer to the medical literature. Ann Intern Med. 1986 Nov;105(5):810-6.

Your patient, a 23-year-old college student ... is developing early signs of retinopathy. She asks whether further retinopathy could be prevented ... You excuse yourself from the patient and step into the room that contains your office computer. You ... type in four letters that stand for the computer program that connects you with the National Library of Medicine`s current MEDLINE file. The system gives you a polite computer welcome, and then you type in the terms diabetic retinopathy and insulin infusion systems. MEDLINE replies that 38 articles are classified with both these descriptors. You then type in 1 and random allocation ... You ask for a printout of the titles, authors, and abstracts of these articles. The online search time for the session was less than 2 minutes, and the search charge was just $0.93 . One of the articles that MEDLINE selected is a recent issue of NEJM, so you direct your computer to contact the Colleague full-text service ... and ask for a printout of the complete article. ... You return to the patient, whose mild annoyance at having been kept waiting for 10 minutes turns to amazed admiration when you hand her a copy of the abstracts and indicate that you do not feel pump therapy has yet shown that it can be helpful in controlling diabetic retinopathy.

Our objectives

• See how far we’ve come!• Tour selected clinical resources to show your

options • Review some ways of keeping current• Demo handheld use in practice• Collect information management tips and

tricks from the audience

Judging clinical resources

Content Ease of use Evidence based Currency Platforms/Formats Cost Special features

Tour of options

Clinical Evidence Dynamed Essential Evidence PEPID UptoDate

FORMAT, PLATFORMS & AVAILABILITY

Clinical EvidenceOnline, handheld, print

U Manitoba, individual subscription

Palm; Pocket PC; Windows Mobile �

DynamedOnline, handheld

Individual subscription Palm; Pocket PC; Windows Mobile; Smartphone; BlackBerry ;iPhone iPod Touch

Essential Evidence Plus Online, handheld

CMA, U Manitoba, individual subscription

Palm; Pocket PC; Windows Mobile

PEPIDOnline, handheld

Individual subscription Palm; Windows Mobile;BlackBerry; Mobile Wireless Devices; iPhone; iPod Touch

UptoDateOnline, CD, handheld

U Manitoba, individual subscription

Palm; Pocket PC, Smartphone

1. Clinical Evidence

• Systematic reviews on treatment & prevention of 240+ conditions

• Rates interventions →• GRADE evaluations of

quality of evidence• Other features

– Links to guidelines– EBM tools e.g, Methods for calculating risk

BeneficialLikely to be BeneficialTradeoff between Benefits and HarmsUnknown Effectiveness Unlikely to BeneficialLikely to be Ineffective or Harmful

CALCULATORS, SPECIAL REPORTS …

THREE WAYS OF SEARCHING

SEARCH BY SECTION

SEARCH BY REVIEW TOPIC

Clinical Evidence: Interventions Tab

CLINICAL QUESTIONS FOR

THIS TOPIC

RATED INTERVENTIONS

TWO OTHER WAYS TO SEE INFO - KEY POINTS &ABOUT THIS CONDITION

2. Dynamed

• Summaries for ~ 3,000 topics• Evidence summaries focus on patient-oriented

outcomes and absolute risks (NNT, NNH)• Uses Strength Of Recommendation Taxonomy

(SORT) • Quality of evidence labeled Grade A,B, or C• Includes Patient Information links• Kit to integrate with Electronic Health Record

Dynamed: Search results

TYPE SEARCH TOPIC IN WINDOW & LIST OF HITS APPEARS

CAN ALSO SEARCH BY ALPHA TOPIC OR

BROWSE BY CATEGORY

CAN GO STRAIGHT TO THERAPY, DIAGNOSIS

Inside Dynamed Summary

SHOWS LEVEL OF

EVIDENCE

JUMP TO SECTIONS

PATIENT INFORMATON

3. Essential Evidence Plus

• Search multiple databases at once– EBM Guidelines; POEMs; Cochrane Abstracts; Selected

Practice Guidelines; Decision Support & Diagnostic Calculators; Derm Expert; ICD-9 Lookup Tool

• Archive and alerts of POEMS – Patient Oriented Evidence that Matters

• Gives levels of evidence for some resources• Decision Support and Calculators• Handheld versions integrated with Lexi-Comp (must

be purchased separately)

Essential Evidence Plus: search screen

BROWSE BY DATABASE OR TOOL

SEARCH OR BROWSE BY

SUBJECT

POEMS

Essential Evidence Plus: Search resultsICONS SHOWING

DIFFERENT TYPE OF RESOURCE

SHOWS LEVEL OF EVIDENCE

REFINE YOUR

RESULTS IN

DIFFERENT WAYS

4. UptoDate

• ~7,400 topics in 13 medical specialties• ~76,000 pages of text, graphics, links to

Medline abstracts, ~254,000 references• Integrated with Lexi-Interact™ Online• Some levels of evidence in Summary and

Recommendations sections, began in 2006• Patient information free at

http://www.uptodate.com/patients/

UptoDate: Search results

TABS TO REFINE RESULTS

SEARCH BOX

UptoDate: Topic entry

PICTURES

5. PEPID

• ~2000 medical topics • Drug Database with ~7,500 drug, herbal and

OTC generic and trade names• Drug interaction generator - simultaneously

cross reference up to 50 drugs• ~ 250 medical calculators• Links to FPIN (Family Practice Inquiries Network)

questions • Personal Notes - add a note anywhere

PEPID

EASY TO FOLLOW ICONS

PEPID

IMAGES

Research• Bonis PA, et al. Association of a clinical knowledge support system with

improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the United States. Int J Med Inform. 2008 Nov;77(11):745-53.PubMed

• King WJ, et al. Effect of point of care information on inpatient management of bronchiolitis. BMC Pediatr. 2007 Jan 24;7:4. PubMed Provision of clinical evidence from a reputable source at the point of care influenced bronchiolitis treatment choices by medical trainees

• Goodyear-Smith F, et al. DynaMed, MD Consult and UpToDate. Aust Fam Physician. 2008 Oct;37(10):878-82. PubMed This study was unable to show a clear preference or superior utility among three e-textbooks

Research

• Graber MA, et al. Answering clinical questions in the ED. Am J Emerg Med. 2008 Feb;26(2):144-7. PubMed Physicians had 235 questions or approximately 5 questions per 8-hour shift. The 2 most commonly used information sources were drug information resources (Personal digital assistant [PDA], pocket pharmacopeia [37% of the time]) followed by electronic resources (Google, UpToDate [29% of the time])

• McKibbon KA, et al. Effectiveness of clinician-selected electronic information resources for answering primary care physicians' information needs. J Am Med Inform Assoc. 2006 Nov-Dec;13(6):653-9. PubMed For the primary care physicians studied, electronic information resources of choice did not always provide support for finding correct answers to simulated clinical questions ….

Keeping current

Email alerts RSS feeds Podcasts

Email alerts

Journal tables of contents Clinical information

Evidence Updates (formerly BMJ Updates) New articles about X

PubMed (and other databases) News alerts

Google Alerts

Journal Tables of ContentsCLICK HERE

Clinical information

• Evidence Updates From BMJ Publishing• Evidence-based ratings of clinical relevance &

newsworthiness of articles• Tailored to your interest profile & frequency• Critically appraised articles from ~ 130

journals & abstracted systematic reviews from ~800 journals

• Free

SEARCHABLE DATABASE

Evidence Updates in your mailbox

SEE RATINGS

FURTHER COMMENTS BY

CLINICAL RATERS BELOW

Evidence Updates entry

SEE HOW MANY REFERENCES YOU

WOULD GET

Tailoring your Evidence Updates

Alerts - new articles about X

• Example from PubMed but many other databases offer alerts– Topic, author, articles that have cited an article

you like • 3 steps to alerts from PubMed

– Get My NCBI account (free)– Do PubMed search & save it– Fill in dialog box with frequency & other info

CLICK HERE TO SAVE YOUR SEARCH

Customizing your PubMed Alert

PubMed Alert in your mailbox

Google Alerts

• Email alerts can be useful but feeds can be better!

RSS Feeds

• Feeds / RSS feeds / XML feeds / syndicated content / web feeds /Real Simple Syndication

• Contain frequently updated content published by a website

• Used for all types of digital content including pictures, audio, or video

• Instead of you going to the website to check what’s new, RSS delivers it to you

Feed readers

• Also called Aggregators / Readers/ News Readers

• Different types– Standalone programs– Part of other programs e.g. Outlook 2007, Internet

Explorer 7+, Firefox 2+– Web-based e.g. Bloglines, Google Reader

• More information? Check Wikipedia or YouTube

How to get feeds

• See icons on many websites – this will be standard soon

• Some browsers display icon in address bar if site has a feed

• Visit a list or directory of feeds• Use your reader to search for feeds

FEED ICON

Some lists of feeds

• MedWorm http://www.medworm.com/• MedicineNet’s list of feeds

http://www.medicinenet.com/rss/article.htm• CBC http://www.cbc.ca/rss/

Subscribing to feeds

• Click on icon of feed you want – If using Internet Explorer, click on Subscribe to this

feed,and feed is added to the Common Feed List

• Or copy feed address (URL) and paste into your reader window

EASY TO SUBSCRIBE WITH THESE

DIFFERENT READERS

SEARCH FOR FEEDS THAT USE THESE

WORDS

Feeds in Internet ExplorerFEEDS

SUBSCRIBED TO

ITEM FROM HIGHLIGHTED

FEED

Google Reader

• Need a Google account first – highly recommended for lots of reasons

• Accounts are free• Go to Google Accounts Creation page

Inside Google Reader

FEEDS

NO. OF NEW ITEMS

SHOW BRIEF OR EXPANDED VIEW

OF ITEM

PASTE FEED ADDRESS

HERE

TAG ITEMSTO PUT THEM IN

FOLDERS

TAGGED FOLDERS

Inside Google Reader

STAR ITEMS FOR STARRED FOLDER

Inside Google Reader

STARRED ITEMS YOU WANT TO

READ

SHORTCUTS

Inside Google Reader

SEARCH FOR WORDS IN YOUR

FEEDS HERE

YOU CAN SEARCH

FOR FEEDS HERE

Feeds on iGoogle

ADD STUFF

Podcasts Use RSS technology Audio file in MP3 format made available to an

audio player Your computer, iPod, or other MP3 player Feed readers (e.g. iTunes) automatically check for

updates and download new files to your computer Same principles apply to video files (vodcasts) Most are free

Examples of podcasts

• Journal contents & highlights: NEJM JAMA Lancet etc.

• Therapeutics Initiative• EM Rap http://prod4.ccme.org/emrap/• CDC http://www2a.cdc.gov/podcasts/• Johns Hopkins• List at Medical Pills blog• InfoPOEMS

EM Rap

How to subscribe

• Subscribe easily and automatically download to your computer and iPod through iTunes

• iTunes is free• Most podcasts are free • Go to iTunes Store > Podcasts > Science &

Medicine and click on Subscribe icon• OR Manually subscribe by copying and pasting

the address of the podcast you want

Podcasts in iTunes

GO TO SCIENCE & MEDICINE

GO TO PODCASTS

GO TO BROWSE

POEM OF THE WEEK

CLICK HERE TO SUBSCRIBE

Email alerts or RSS feeds?

• Information often available both ways– E.g. Best Evidence, PubMed searches, some

journal alerts• Depends on number of sources you want to

follow• What works for you?

Demo of handheld use in practice

Summary

• Many choices of clinical resources– Keep aware of what ‘s available– Have some criteria for judging

• Different ways of keeping current– some may work better than others for you

• Tips, tricks, and questions from the audience– Send them to clfm@uwo.ca - we’ll post on the

College website with this presentation

Thanks!

Come and try out some resources at the Computer Resource Station in the

exhibits area.