Finding Reliable Clinical Information Online Nancy Clark, M.Ed. Director of Medical Informatics Education FSU College of Medicine Summer An Introduction

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

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

Resources Medical References PowerPoint Assessing the Validity of Online Medical Information Assessing the Validity of Online Medical Information Decision Support Using Drug Resources Summer

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

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

“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 The half life of medical information is estimated at 5 years.

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

Here is the Problem… Summer 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?

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

Assessing the Validity of Information on the Web Site ownership/domain Summer 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

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

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

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

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

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

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

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

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

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

Your eBookshelf Summer

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

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

Books on the Library Web Page Summer

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

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

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

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

Answering Clinical Questions At the Point of Care Summer

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

Current Library Web Site (Sum 2010) Summer

New Library Webpage Summer

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

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

Current Site - New Site Summer

Primary Resources of the Maguire Medical Library Summer

Summer

Differential Diagnosis Tools DxPlain PEPID Summer

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

Summer 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

Drug Information Epocrates Online PEPID Harrison’s Practice Summer

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

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

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

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

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

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

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

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 PDA and Online

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

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 Exercises for Practice

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 Use FireFox

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

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 Exercises for Practice

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

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 Exercises for Practice

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 Ponka, D., et al. Top Ten Differential Diagnoses in Primary Care. [Web Resource] U of Ottowa Accessed at Ten Differential Diagnoses in Primary Care.

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 Recorded by FSU CoM Students in 3 rd year Clerkships

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 PDAs to be distributed in August 25-27

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