EBM for the busy Clinician Putting your Smart Phone to Work Gil C. Grimes, MD

Bias Identification Slide I have reviewed sections in DynaMed in the past I do not have any commercial affiliations outside Health PEI I am from Texas and at times may feel better about myself than required by law. I like technology.

Why Bother?

Objectives Levels of Evidence DOE vs. POEMs Sources for Evidence Tools for the Bedside Non-medical Handheld Tools

First a few Questions I am familiar with Evidence Based Medicine? Databases and sites that I routinely use to obtain information?

What is EBM? Simply put it is the integration of research evidence with clinical expertise and patient values. EBM will allow us to do more good than harm Patients want to know the following o Will it make me live better o Will it make me live longer

Levels of Evidence This is a method for grading journal articles, guidelines etc. This is not universal AAFP uses Level A, B, C Centre for EBM Oxford uses 1,2,3 o Focuses on the type of article and quality o Therapy/Prevention/Etiology/Harm, Diagnosis, Prognosis Either way is just fine

Wheres the beef? Levels of evidence are good…. What I want to know is how this will work for me. Friends the path requires moving from DOE to POE…

Disease Oriented Evidence Most common type of evidence found in research journals Important to our understanding of disease Responsible for many therapeutic advances Intended for a research audience Pathophysiology Pharmacology Etiology

Patient Oriented Evidence Uncommon in most journals Outcomes patients care about Mortality Morbidity Quality of Life Cost Harm

POEMs Patient-Oriented Evidence that Matters o Addresses a clinical problem encountered by primary care physicians o Uses patient-oriented outcomes o Potential to change our practice if valid and applicable

DOES vs. POEMs The Numbers…. o 6 month survey of 90 journals o 8,047 articles o 213 POEMs 97% DOEs and other material 2.6% POEMs J Fam Pract 1994;38:

So where do I find this? You could search the literature o Yeah like you have that much time! You could ask you colleagues o Expert opinion Level C You could familiarize yourself with one or two good sources o That sounds pretty good…

Usefulness equation Usefulness= relevance x validity work Go for sources that have done the work for you

Systematic Reviews Summarized Evidence- Referenced Resources Research Articles Other Sources

Search Strategies Database Size o Larger the database, tighten the search o Small database, broaden the search Language o A little time on a tutorial can save you hours over a month o Especially PubMed

DynaMed Created by Brian Alper, MD Evolved from his black book of facts Background information o Better for review than Up-to-date o Discusses diagnosis, treatment, etc. Evidence based Peer reviewed Can be used to generate scholarly activity in residency I use this resource multiple times daily

DynaMed Supported Devices o Palms o Pocket PC o Windows Smartphone o BlackBerry o iPhone and iPod Touch Android Smartphones Web Based availability

Essential Evidence Plus Founded by three Family Physicians, a PharmD and a Psychologist Goal to improve the health and lives of people by providing patient-oriented evidence that matters in a rapid and accessible form Very good on computers, OK on handhelds

Essential Evidence Plus Essential Evidence are good quick summaries (slightly shorter than Dynamed) o Nice bottom line approach to disease o Not as frequently updated o Little clunky on the BlackBerry Calculator Section very useful o Mortality, warfarin, pre-op eval etc. Lets Look

Web Based Stuff Trip Database- an aggregator service for medical data that sorts by Level of EvidenceTrip Database- o Excellent resource for patient handouts o Free PubMed- great site for research, no really, you just have to know how to use it.PubMed

Relevance Slice the bedside stack o Is this something that is common to my practice? o Is it an outcome my patients would care about? o If the outcome is true would I have to change my practice? If relevant then examine for validity

Pushed or Pulled Keeping up in medicine is tough Pushed information helps o InfoPOEMS o Journal Contents Pulled Information o Learning as you need to o Just in time information

Handhelds This is the key to just in time information InfoRetriever and DynaMed can run off Palm or Microsoft handheld Very functional Gives you decision tools in your hand when you need them

Programs worth Having Epocrates iSilo LyteMeister ICD Meister CPT Meister Geriatrics at your FingertipsGeriatrics at your Fingertips Family Practice Management has a good article o July/August 2006

Demonstrations of Handheld

Non-medical Programs Google Bookmarks o Evernote o o A means to an end for keeping everything in the cloud reQall o o Reminding yourself of things you forgot

Questions?