EBM for the busy Clinician ‘Digital Brains for those who forget’ 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 Why I care Some EBM Terms Sources for Evidence Tools for the Bedside Non-medical Handheld Tools Demo of my Practice

Why I care about EBM Started Practice In Dugway UTAH 1996 No internet, no EBM, limited resources Limited Training Lots of Responsibility

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

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

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 (in my opinion) 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 BlackBerry o iPhone and iPod Touch o Android o In order to download you need SkyScape Web Based availability via CMA

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. o Register to get username for mobile access (a little easier to use) CMA access

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 DynaMed Updates 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 Essential Evidence Plus and DynaMed can run off Blackbery, Android or iPhone/iPod Very functional Gives you decision tools in your hand when you need them

Programs use most days Epocrates QxCalculate ePSS MediBabble SayHi Geriatrics at your FingertipsGeriatrics at your Fingertips Family Practice Management has a good article o May/June 2013 o 012/0500/p10.html 012/0500/p10.html

Non-medical Programs Google Bookmarks (a means for sharing bookmarks across platforms) DropBox Use at the office as our central repository Evernote o o A means to an end for keeping everything in the cloud

Questions?