1. Finding Reliable Clinical Information Online Nancy Clark, M.Ed. Director of Medical Informatics Education FSU College of Medicine Summer 20101 An Introduction http://www.med.fsu.edu/informatics/MedicalReferences.asp

2. Major Competency Students will Demonstrate the ability to acquire new data and information and to critically appraise its validity and applicability. Summer 2010 2

3. Objectives of Session Students will Demonstrate ability to locate quality clinical information on the web utilizing a variety of strategies Assess the reliability and validity of clinical information found using search engines on the web Begin to utilize the FSU COM virtual library resources to locate medical information for clinical decision support [Old and new] Summer 2010 3

4. Resources http://www.med.fsu.edu/informatics/ Medical References PowerPoint Assessing the Validity of Online Medical Information Assessing the Validity of Online Medical Information Decision Support Using Drug Resources Summer 2010 4

5. Review What is the most efficient, unbiased way to keep up to date? 1. Go to conferences 2. Read 20-30 journal articles a week 3. Look up answers to clinical questions when they occur in a reliable, current resource Summer 2010 5

6. In the Beginning… Summer 2010 6 Journals Text Books Drug Info Pocket Manuals Note Cards Peer Reviewed

7. “Textbooks don’t smell as their contents rot, so readers will need to develop alternative crap detectors to avoid poisoning their minds and robbing their patients of current best care.” David Sackett, MD Pioneer of Evidence Based Medicine (EBM) Summer 20107 The half life of medical information is estimated at 5 years.

8. Note Cards Journals Text Books Drug Info Pocket Manuals 21 st Century Medical Information Summer 2010 8

9. Here is the Problem… Summer 2010 9 Which of these sites are accurate? Which of these sites are reliable? Which of these sites are up to date? Which of these sites are not biased?

10. AMA Guidelines for Medical and Health Information Sites on the Internet AMA Guidelines for Medical and Health Information Sites on the Internet Health on the Net Code of Conduct HON Health on the Net Code of Conduct Assessing the Validity of Information on the Web Summer 2010 10

11. Assessing the Validity of Information on the Web Site ownership/domain Summer 2010 11 Gov –CDCCDC –AHRQAHRQ –NLM.NIHNLM.NIH –DHHSDHHS –FDAFDA –States fl.us Edu –Medical Centers Org –Associations AAFP ACP ACOG –Disease orgs ADA ALA Com –Commercial

12. Assessing the Validity of Information on the Web Site ownership/domain Contributors listed, credentials, contact info Highly referenced, linked to primary literature MEDLINE Abstracts/Journal Articles Proceedings from scientific meetings Timeliness: date posted, revised Viewer access, payment and privacy Funding and sponsorship Summer 2010 12

13. Wikipedia List 5 ways Wikipedia does not fit the criteria as a reliable site. Summer 2010 13

14. Exercise Search Google for treatment of back pain Rate the first 20 hits Sponsor? Advertisements? Audience? Authors? Links? Date Revised? Do advanced search limit to.gov domain and compare results Search for prostate cancer screening Summer 2010 14

15. Types of Information Found Free on the Web Information for/by students Information for/by patients Information for/by clinicians Information for/by researchers Sales pitches, ads Quacks who want to sell something Unproven, unsubstantiated nonsense Summer 2010 15

16. Assessing the Validity of Information on the Web Library subscription resource = reliable Summer 2010 16

17. Be Skeptical You will be taught the principles of critical review of the literature in your second year along with Evidence Based Medicine (EBM) Summer 201017

18. What Kind of Question Do I Have? Basic science or background question? What is an olecranon? Clinical question? What are the risk factors for hypertension? Which is better for diagnosing pneumonia: x-ray, CT or MRI? How should I treat otitis media? How much does amoxicillin cost? Summer 2010 18

19. Answering a Background Question Searching most efficient Google/Wikipedia (assess the validity) Use Medical Dictionary Basic Science Textbooks Access Medicine Thieme Summer 2010 19

20. Searching with Google Summer 2010 20 Web Based Medical Information Google Search Free $ubscription

21. Your eBookshelf Summer 201021

22. Medical Dictionaries Stedman’s is at eMedicine, in PEPID Dorland’s at Merck Summer 2010 22

23. Using Stedman’s Medical Dictionary eMedicine online PEPID online and PDA Look up: dyspneanephrolithiasis teratogeniciatrogenic epistaxis cyanosis Summer 2010 23 Exercises for Practice

24. Books on the Library Web Page Summer 2010 24

25. When to Use eBooks versus Quick References Background information on topic Basic science question instead of disease specific question Detailed information/explanations versus bottom line Lots of time versus short on time Zebras versus common problems Summer 2010 25

26. WebFeat Search Searches Library Resources Pick the type of resources to search Groups by resource Uses resource search engine Summer 2010 26

27. New Website Searches Multi-Search = Webfeat Changing to SerialSolutions 360, August 2010 Only eBooks and Patient Education Summer 2010 27

28. Access Medicine Best selection of all basic science books Combined with good clinical medicine books Search productive Summer 2010 28

29. Answering Clinical Questions At the Point of Care Summer 201029

30. Answering Clinical Questions Quickest method: Browse to specific resource Requires: knowing the content of sites/resources Starting point: Library web page or your handheld (iPod or cell phone)Library Learn to use subscription resources Summer 2010 30

31. Current Library Web Site (Sum 2010) Summer 2010 31

32. New Library Webpage Summer 2010 32

33. Access Issues IP address verification Limited simultaneous users Special URL issues Bottom Line Use links on Library Homepage Summer 2010 33

34. Off Campus Access IP authentication Proxy server – EZProxy FSU COM ID and password Use links on library page Summer 2010 34

35. Current Site - New Site Summer 2010 35

36. Primary Resources of the Maguire Medical Library Summer 2010 36

37. Summer 2010 37

38. Differential Diagnosis Tools DxPlain PEPID Summer 201038

39. Differential Diagnosis Tools Enter symptoms or chief complaint Get a differential Get more info on disease DxPlain ***** DxPlain Harvard Allows for multiple symptoms and lab results Drawback: Slow PEPID *** PEPID Multiple symptoms Lab Results Age, gender, duration eMedicine ** Access Medicine’s Diagnosaurus* (DDX tab) Summer 2010 39

40. Summer 2010 40 Using DxPlain or PEPID Patient 35 yr old female Chief complaint – fatigue, duration 2 months Other symptoms: throat pain, cold intolerance, weight gain, bradycardia, and constipation, Differential? Add lab: elevated TSH Exercises for Practice

41. Drug Information Epocrates Online PEPID Harrison’s Practice Summer 201041

42. Epocrates Online Rx, OTC and Alternative medicines by brand name, generic, and by class Formularies Drug Interaction tool Disease reference, pill identifier, medical calculators, tables Constantly updated Summer 2010 42

43. Epocrates Drug Interaction MultiCheck Tool Add all the drugs on the patients medications list (Rx, OTC, Alt) plus drug considering Look to see if any interactions What is the severity of interaction

44. PEPID CRC Suite Rx, OTC and Alternative medicines by brand name, generic, and by class Drug Interaction tool DDx, Disease reference, Lab manual, medical calculators, clerkships, images Constantly updated Summer 2010 44

45. PEPID Drug Interaction Tool Select all drugs on list Say Done Click Interactions Click specific interaction to read details Summer 2010 45

46. Exercises for Practice Using Epocrates Online How should you prescribe acyclovir for chicken pox in an immunocompromised patient? (dose) How much do 9 (50 mg) tablets of Imitrex cost? (common migraine drug) Are there any drug interactions between Lexapro, Lortab, Xanax and Zocor? Summer 2010 46

47. Disease Quick References DynaMed (Web and PDA) eMedicine (Web and PDA) Harrison’s Practice (Web and PDA) Epocrates Dx PEPID Summer 201047

48. Types of Questions Best Answered by Disease Quick References Description/background Epidemiology Diagnosis Treatment Ongoing management Prognosis/outcomes Prevention Summer 2010 48 Bottom Line

49. DynaMed Most comprehensive disease reference Summarizes all the latest research on topic Very detailed Well organized Links out to full text articles if more details needed Includes both diseases and symptoms like chest pain Summer 2010 49 PDA and Online

50. DynaMed Organization: Includes History and Physical sections (why am I asking these questions) Expand or collapse sections Use CTRL-F to search page Summer 2010 50

51. Using Dynamed -- Question: What is the typical history of present illness for someone with SARS? Type in SARS or use alphabetical listing Explode History Dynamed Exercise Summer 2010 51 Exercises for Practice

52. Moderate amount of detail and information Several monographs on one topic by different specialties Google searches it Now owned by WebMD/Medscape. Suggest registering. One of Student’s favorite iPhone version in Medscape eMedicine Summer 2010 52 Use FireFox

53. eMedicine Monographs Subscription eliminates ads found on free Medscape site One long page of information Navigation clunky, inconsistent Summer 2010 53 CTRL-F

54. Using eMedicine - Question: What is the functional anatomy when you have a Rotator Cuff Injury? Search or browse to Rotator Cuff Injury. Use Sports Medicine article. Select Introduction Summer 2010 54 Exercises for Practice

55. Harrison’s Practice Internal Medicine focus Linked to Access Medicine content Has drug information from GoldStandard Nice navigation on left side Summer 2010 55 PDA and Online

56. Using DynaMed, eMedicine, Epocrates and/or Harrison’s Practice: Develop a scenario for CSSC practice Complete form provided (optional) Pick from diseases top 10 DDx in primary care or top 20 diagnoses seen by students Complete electronically (form on Blackboard) Change file name to your name ( John_Doe.doc) Upload to Blackboard Assignments Tab on D101 BB by Friday the 7/23/09, by midnight Summer 2010 56 Exercises for Practice

57. Top 10 Chief Concerns 1. Cough 2. Fatigue 3. Low Back Pain 4. Fever 5. Dyspnea 6. Generalized Abdominal Pain 7. Headache 8. Vertigo 9. Chest Pain 10. Edema Summer 2010 57 Ponka, D., et al. Top Ten Differential Diagnoses in Primary Care. [Web Resource] U of Ottowa. 2006. Accessed at www.familymedicine.uottawa.ca/Top Ten Differential Diagnoses in Primary Care. www.familymedicine.uottawa.ca/

58. Top 20 Diseases 1. Hypertension11. Obesity 2. Depression12. Gall Bladder disease 3. Hyperlipidemia13. GERD 4. Diabetes Type 214. Asthma 5. Bipolar disorder15. Sinusitis 6. Anxiety disorder16. Substance abuse 7. Cold/URI17. COPD 8. ADHD18. Coronary Artery Disease 9. Otitis media19. Peripheral vascular disease 10. Schizophrenia20. Pneumonia Summer 2010 58 Recorded by FSU CoM Students in 3 rd year Clerkships

59. iPod/iPhone/iPad Versions Clinical Evidence DynaMed Epocrates Essentials Essential Evidence+ Harrison’s Practice PEPID Geriatrics at Your Fingertips Free resources ePSS USPSTF Tool Mobile Merck Medicus Medscape Summer 2010 59 PDAs to be distributed in August 25-27

60. Review Name three things you should look for in a web site with medical information that would make you feel more confident about the content of that website. What resources are going to be the most accurate, reliable, and up to date? Name a library drug reference, a differential diagnosis resource, and a disease quick reference Summer 2010 60