SETTING YOUR SITES ON EFFECTIVE INFORMATION MANAGEMENT Lynn Dunikowski & Mike Dillon 51 st Annual Scientific Assembly Manitoba College of Family Physicians April 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 Nov;105(5): 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 weve 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 Evidence Online, handheld, print U Manitoba, individual subscription Palm; Pocket PC; Windows Mobile™ Dynamed Online, handheld Individual subscriptionPalm; Pocket PC; Windows Mobile; Smartphone; BlackBerry ; iPhone iPod Touch Essential Evidence Plus Online, handheld CMA, U Manitoba, individual subscription Palm; Pocket PC; Windows Mobile PEPID Online, handheld Individual subscriptionPalm; Windows Mobile; BlackBerry; Mobile Wireless Devices; iPhone; iPod Touch UptoDate Online, 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 Beneficial Likely to be Beneficial Tradeoff between Benefits and Harms Unknown Effectiveness Unlikely to Beneficial Likely 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 results ICONS 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

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 Nov;77(11): PubMedPubMed King WJ, et al. Effect of point of care information on inpatient management of bronchiolitis. BMC Pediatr Jan 24;7:4. PubMed Provision of clinical evidence from a reputable source at the point of care influenced bronchiolitis treatment choices by medical traineesPubMed Goodyear-Smith F, et al. DynaMed, MD Consult and UpToDate. Aust Fam Physician Oct;37(10): PubMed This study was unable to show a clear preference or superior utility among three e-textbooksPubMed

Research Graber MA, et al. Answering clinical questions in the ED. Am J Emerg Med Feb;26(2): 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])PubMed McKibbon KA, et al. Effectiveness of clinician-selected electronic information resources for answering primary care physicians' information needs. J Am Med Inform Assoc Nov-Dec;13(6): 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 ….PubMed

Keeping current alerts RSS feeds Podcasts

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 Contents CLICK 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

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 whats 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 MedicineNets list of feeds CBC

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 Explorer FEEDS 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 pageAccounts Creation

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 CDC Johns Hopkins List at Medical Pills blogMedical Pills 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

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 - well post on the College website with this presentation

Thanks! Come and try out some resources at the Computer Resource Station in the exhibits area.