2. Exercises for Practice
• Diagnosis: What is the sensitivity, specificity and LR
for procalcitonin in acute infections?
• Prevention: Starting a patient on Aspirin: Who should
be offered a Proton Pump Inhibitor?
• Risk assessment: How to assess for a DVT risk?
• Risk assessment: How to assess the severity of acute
pancreatitis?
• Quality Improvement: What is the role of Point-ofCare computer reminders in improving patient care?
3. Exercises for Practice
• Therapy: An 8 year old girl who is 60 pounds
(27.2 kg) has moderate dehydration. What
should her maintenance fluids in mL per 24
hours be?
• Therapy: Anti-coagulation in patients with
cerebral hemorrhage?
• Risk assessment: Calculate your own ATPIII 10
year risk for heart disease based on your age,
gender, cholesterol and smoking status.
Session 5
3
4. Exercises for Practice
• Medication Side-Effect: A basic metabolic
panel reveals that a 30 year old man suffering
from bipolar disorder has a serum calcium
level of 12.9 mg/dL. He is taking lithium and
valproate. Could his medications be a factor?
• Therapy: A patient was admitted with an
ulcer related upper GI hemorrhage. Outline a
management plan and timing of endoscopy.
• Therapy: Nebulized epinephrine or steroids for
croup in children—are they recommended?
4
5. Exercises for Practice
• You have a male 42 yr old present in the ER with a severe
headache, nausea, myalgia, malaise, prostration. This
just started suddenly a day or so ago. Physical exam
reveals generalized macules that are red, fever, skin
erythema, generalized papules that are small red, rash on
his palms and soles of his feet. He thinks he has had
insect bites while camping recently.
• What could this be?
– http://www.ddderm.blogspot.com/
6. Exercises for Practice
• Calculators: What is the predicted peak flow
for a 60 year old woman with asthma? She is
5’2”.
• Drug Interaction: A patient on carbamazepine
for epilepsy is due to be started on
ciprofloxacin..any problem?
• Patient Education: an obese patient (BMI 32.6)
is due to start on olanzapine—what advice
should she receive?
Session 5
6
7. Exercises for Practice
• Patient Education: A patient with AF is due to
start warfarin..he is requesting to know more?
• Prognosis: A 40 year old woman has just had a
mastectomy. She had a grade 1 tumor, no
lymph nodes and no lymphatic or vascular
invasion. What is her Breast Cancer
Recurrence risk?
Session 5
7
8. Exercises for Practice
• Calculate your own Body Mass Index, Ideal Body
Weight, Basal Energy Expenditure, and Body Surface
Area.
• 81 year old female with long standing diabetes, and
hypertension. Her BP is usually 140-150/85-90. Her
ideal body weight is 74 kg. Laboratory tests: serum
creatinine 112 umol/dl, Hgb A1C 7.8, liver function
tests normal. What is her creatinine clearance?
Session 5
8
9. Exercises for Practice
• A basic metabolic panel reveals that a 30 year
old woman recovering from trauma has a
serum chloride level of 108.9 mEq/L. She is
taking ASA. Could her medications be a
factor?
Session 5
9
10. Exercises for Practice
• In acute respiratory distress syndrome, during the
exudative phase, what findings appear on a chest xray?
• What is the mortality rate for Rocky Mountain
Spotted Fever?
11. Exercises for Practice
• A 65 year old woman is worried that she may get
Parkinson’s Disease because her father was
diagnosed with it when he was 65. He was a heavy
smoker. She does not smoke or drink alcohol or
coffee. What do you tell her?
• What is the prognosis for a 60 y/o female with Stage
IV metastatic breast cancer?
12. Exercises for Practice
• A 45 year old man has been a smoker for over
20 years is worried that he might have
diabetes mellitus because his father had it. He
does not think anyone else in his family has
ever been diagnosed with it. He is 6 feet tall
and weighs 250 pounds. What is his Diabetes
risk score? You will first need to determine his
body mass index.
Session 5
12
13. HEALTH CARE LITERACY IS ESSENTIAL TO
THE MEDICAL TEAM
Every organization can
benefit from speeding up
its information
metabolism.
This metabolism is the
process by which content
is produced and
consumed.
14. Point-of Care Resources & Tools:
Implementing Evidence &
Transforming Healthcare Provision
Dr. Imad Salah Ahmed Hassan MD FACP FRCPI MSc MBBS
Consultant Physician & Pulmonologist
Chairman, Knowledge Translation Committee
Department of Medicine
KAMC
Riyadh
Kingdom of Saudi Arabia
15. The Patient Journey: Chances of Error?
Treatment
Medication and prescriptions
Symptoms
and history
Body physical
examination findings
Advice and education
Hypotheses,
Self management and
health issues
home monitoring
Chronic
(problems and
Conventional medical summary
Prevention
Well-being and fitness, and
disease
diagnoses), rehabilitation after illness
risks
screening,
management
population health
Tests and investigations
measures
Care planning
Social welfare, culture, religion,
attitudes, expectations, hopes,
fears
Procedures and operations
Communication, team-based collaboration
Consent, permissions, disclosures, complaints
Protocols, guidelines, care
pathways
16. Is there a clear need for change:
Characteristics of current Heath care? T/F
1. High Efficiency & Productivity
2. Contained Healthcare Costs
3. Guaranteed Good Clinical Outcomes
4. High Patient Care Quality (No Medical Errors)
5. No Unnecessary & Duplicate Tests
6. High Patient Satisfaction
7. High Patient Engagement
8. Comprehensive Dual Preventive as well as Therapy Inputs
17. Patient Safety & Quality Gaps
Acknowledged
• “98,000 Hospital
Patients Die Yearly
Because of Adverse
Events” (IOM, 1999)
• “Virtually Every Patient
Experiences a Gap Between
the Best Evidence and the
Care They Receive” (IOM,
2001)
Medical errors kill enough
people to fill four jumbo jets a
week!!!!
20. Summary:
Access to Evidence-Based Information
• Push
• Pull
System
Summaries
Synopses
Synthesis
Studies
• Prompt…..some labs and eMRs with a credible evidencebased pedigree
2009
21. eHealth & mHealth
eHealth
eHealth is a broad term
for healthcare practice
which is supported by
electronic processes and
communication.
The term can encompass
a range of services that
are at the edge of
medicine/healthcare and
information technology.
mHealth
Mobile Health
Mobile technologies such
as mobile phones to
collect and access health
information.
22. Health Informatics
The intersection of information science,
computer science, and health care.
It deals with the resources, devices and
methods required to optimize the acquisition,
storage, retrieval and use of information in
health.
23. Why Health Informatics?
Health Informatics provides information to
make decisions
Better information leads to better decisions
leading to better outcomes
Health care, management, planning and policy
all need good information
24. Point-of-Care Resources & Tools:
POCR&T
• Definition
• Its’ Place: Where in Knowledge Translation
Science
• Uses:
– Evidence-based Knowledge Acquisition
– Decision Making
• Diagnosis
• Therapy
– Patient Centered-Care and Education
– Resident/Student education
• Examples
25. What are Point-of-Care R &T?
• Point-of-care resources and tools are those
research and reference utilities that a clinician
can employ immediately at the point-of-care
with a patient: (Clinic, ward, home, ER etc) .
• They are often easy to use and contain filtered
information.
• Most of the evidence-based point-of-care tools
include levels of evidence, rating scales or grade
recommendations as well as citations back to the
original research studies, systematic reviews, or
guidelines.
26. POCR&T
Aim:
Identify useful resources to answer clinical questions
quickly –
• Use the differential diagnosis tools
• Locate disease quick references
• Use online and PDA Calculators
– Medical equation
– Clinical rules, decision support
• Find laboratory information
• Use resources with students
28. Evidence-based Practice
Ask clinical
Acquire the
questions
best evidence
Assess
effectiveness,
efficiency of
EBM process
5A’s !!
Appraise
the evidence
Apply
evidence to
Your patient
29. Secrets of Literature Searching
• Know how to ask a question
– Foreground: Diagnosis, Therapy, Prognosis
– Background: Epidemiology, Etiology,
Pathophysiology etc
• Know where to look: Time is money!
– EBM resources:
• Primary literature
• Secondary literature
– Other resources: Decision Support, Quality
Improvement, Patient Education etc
30. Ask Clinical Questions: PICO
Components of Clinical Questions
Patient/
Population
Intervention/
Exposure
Comparison
Outcome
In patients with
acute MI
does early treatment with a statin
compared to
placebo
decrease cardiovascular mortality?
In women with
suspected
coronary disease
what is the
accuracy of
exercise ECHO
compared to
exercise
ECG
for diagnosing
significant
CAD?
In postmenopausal
women
does hormone
replacement
therapy
compared to no
HRT
increase the
risk of
breast cancer?
31. Secrets of Literature Searching
• Strategies for Literature Searching:
Strategy 1:
Background Knowledge: Textbooks/eTextbooks e.g. emedicine
Strategy 2:
Foreground Knowledge: Primary Literature/Original Studies=
Pubmed
32. Secrets of Literature Searching
• Strategies for Literature Searching:
• Strategy 3:
Foreground Knowledge: Secondary Literature/Pre-appraised
Literature
• Focused/Specific
• Broad/General Topic
33. •
Diagnosis e.g.
– Troponin in ACS
– Uric acid in Pre-eclampsia
•
Therapy e.g.
– Misoprostol for PPH
– Statins for
hypercholesterolemia
– Specific procedure
Systematic
Review
Sites
Technology
Assessment
Sites
Guidelines
Evidence Based eTextbooks
34. Broad/General Topic
Management of PPH
Management of hypertension Guidelines
Management of Fetal Respiratory
Distress Syndrome
Evidence
Based
Management of cancer pain
eTextbooks
On-line
eTextbooks
35. The Effectiveness of Mobile-Health Technologies to Improve
Health Care Service Delivery Processes: A Systematic Review
and Meta-Analysis. Caroline Free et al. Published January 15, 2013
• Background: Mobile health interventions could have beneficial
effects on health care delivery processes. We aimed to conduct a
systematic review of controlled trials of mobile technology
interventions to improve health care delivery processes.
• Conclusions:
1. The results for health care provider support interventions on
diagnosis and management outcomes are generally consistent
with modest benefits.
2. Trials using mobile technology-based photos reported reductions
in correct diagnoses when compared to the gold standard.
3. SMS appointment reminders have modest benefits and may be
appropriate for implementation. High quality trials measuring
clinical outcomes are needed.
37. 5S Information Resources: Information in top 4 are used
Computerized Decision
Support System (CDSS)
Systems
Evidence based textbooks :UpTo
POCRaTs
Summaries
Synopses
Syntheses
Studies
Date, DynaMed, ACP PIER, BMJ Clinical
Evidence
Evidence based journals
EBM, EBN, EBMH, ACP J club
Systematic Review
Cochrane reviews
Original articles:
BMJUpdates, PubMed
Clinical Queries
Haynes, R. (2006, November). Of studies, syntheses, synopses, summaries, and systems: the 5S evolution of information services for
2009
NCKUFM-YCY
evidence-based health care decisions. ACP Journal Club, 145(3), A8-A9.
38. Hierarchy of Evidence-Based
Implementation Tools: POCR&T are at the TOP
The Implementation
Pyramid
Interventions
of variable
effectiveness
•Audit and
feedback
•Use of local
opinion leaders
•Local consensus
processes
(ownership)
•Patient mediated
interventions
Consistently effective
interventions
•Educational outreach visits
•Reminders (manual or
computerized)
•Multifaceted interventions*
•Interactive educational
meetings (workshops)
•Financial Incentives
Interventions that have little or no effect
•Educational materials (Printed practice guidelines,
audiovisual materials, and electronic publications)
•Didactic educational meetings (such as lectures)
* (a combination that includes two or more of the following: audit and feedback, reminders, local consensus
processes, or marketing)
39. 5S Information Resources
Computerized Decision
Support System (CDSS)
Systems
Evidence based textbooks :UpTo
POCRaTs
Summaries
Synopses
Syntheses
Studies
Date, DynaMed, ACP PIER, BMJ Clinical
Evidence
Evidence based journals
EBM, EBN, EBMH, ACP J club
Systematic Review
Cochrane reviews
Original articles:
BMJUpdates, PubMed
Clinical Queries
Haynes, R. (2006, November). Of studies, syntheses, synopses, summaries, and systems: the 5S evolution of information services for
2009
NCKUFM-YCY
evidence-based health care decisions. ACP Journal Club, 145(3), A8-A9.
41. Clinical Workflow: Where Do P-o-C R &
T fit?
Point-of-Care Resources and
Tools are Reminder and
Decision Making Utilities
for Enhancing the Practice
of Evidence-Based Medicine
(Knowledge Translation)
P-o-C R & Ts Fit in all Steps.
42. The Reminder Systems at the Point-of Care:
The P-o-C R & T
Computerized
Decision
Support
Systems
Integrated Care
Pathways,
Protocols and
Order Sets
Best
Available
Evidence
Point-of-Care
Educational
Resources
(Healthcare Provider &
Patient)
Cognitive
Reminders
45. General Characteristics
• Searchable Up-to-Date Medical Databases
• Clinically organized summaries and reference tools
integrating evidence-based and practical information
for decision-making in clinical practice: support in
making diagnoses, creating treatment plans, and
determining prognoses.
46. General Characteristics
• Variable:
• Diagnosis/Differential Diagnosis aids, Laboratory
Reference Values, Decision Trees, Procedures,
Calculators/Unit and Dose Converters, Drug
Reference/Interactions, Videos and Images, Patient
Information, Links to EBM websites, PDA/Online,
emailing facility, notes entry, feedback etc.
47. DynaMed
http://www.dynamicmedical.com/
Essential Evidence Plus (formerly
InfoRetriever)
http://www.essentialevidenceplus.c
First Consult
http://www.firstconsult.com/
UpToDate
http://www.uptodate.com/
Clinical Evidence
http://clinicalevidence.bmj.com/ceweb/index
.jsp
ACP PIERS
http://pier.acponline.org/index.html
PEPID
om/
http://www.pepid.com/
ClinicalKey
http://info.clinicalkey.com/
JBI COnNECT (Clinical Online Network of
Evidence for Care and Therapeutics)
http://connect.jbiconnectplus.org/Default.asp
x
Nursing Reference Centre
http://www.ebscohost.com/nursing/products
/nursing-reference-center
51. VisualDx
With over 25000 images representing more
than 1200 pediatric & adult conditions,
VisualDx allows physicians to search by
diagnosis, build a patient-specific differential,
or look up drug-induced adverse reactions by
medication.
http://www.visualdx.com/features/mobileaccess
52. Resource
Rx
DxPlain Online
DDx
Dx LAB Calcs
X
Epocrates Essentials PDA
X
Epocrates Online
X
UpToDate
X
X
X
X
X
PEPID Online and PDA
X
X
X
X
X
Dynamed Online and PDA
X
X
Harrison's Practice Online and PDA
X
X
Essential Evidence Plus Online and PDA
X
Pediatric Care Online Online
X
X*
X
X
X
X
X
X
Online
X
X
X
X
53. Point of Care Clinical Resources:
Systematic Reviews & CATs Websites
54. Cochrane:
http://www3.interscience.wiley.com/cgibin/mrwhome/106568753/HOME
Database of Systematic Reviews of
effectiveness DARE:
http://www.crd.york.ac.uk/crdweb/
Pubmed Systematic Reviews:
http://www.ncbi.nlm.nih.gov/pubmed/clinical
AHRQ EPC Evidence Reports: Agency for http://www.ahrq.gov/CLINIC/epcquick.htm
Healthcare Research and Quality:
Best BETs:
http://bestbets.org/database/browse-bets.php
Attract:
http://www.attract.wales.nhs.uk/
55. • JAMAevidence
• The JAMAevidence mobile view features a
portion of the site's content optimized for mobile
browsers.
• They are:
“Quick Reference" pocket cards from Users'
Guides to the Medical Literature”
"Make the Diagnosis" sections from The Rational
Clinical Examination
56. Point of Care Clinical Resources:
Clinical Pathways & Protocols
57. NICE Pathways: guidance at your
fingertips- www.nice.org.uk
http://pathways.nice.org.uk/
Society of Hospital Medicine:
http://www.hospitalmedicine.org/
http://www.hospitalmedicine.org/Content/Navi
gationMenu/QualityImprovement/QIClinicalTools
/Quality_Improvement.htm
ICSI Institute for Clinical Systems
Improvements: http://www.icsi.org/in
dex.aspx
(Order Sets)
https://www.icsi.org/guidelines__more/search_r
esults__browsing/?catalog_search_panel_query=1&cat
alog_search_panel_label_ids%5B%5D=98&catalo
g_search_panel_label_ids%5B%5D=99&catalog_s
earch_panel_label_ids%5B%5D=102&catalog_se
arch_panel_label_ids%5B%5D=141&catalog_sear
ch_panel_label_ids%5B%5D=101#results_header
59. Point of For Clinical Resources: Decision Tools
Resources Care EBM Knowledge Translation
Decision Support
Systems
Software to aid clinical decision-making:
characteristics of patient are matched to knowledge base,
recommendations are presented to the clinician/patient.
(Sim et al, JAMIA, 2001)
Objectives:
Diagnostic support
Drug dosing
Preventive care reminders/risk assessment
Disease management (Diabetes, Hypertension, AIDS, Asthma)
Test ordering
Drug prescription
61. CDSS - Benefits
• Improve patient safety
– Reduce medical errors
– Improved medication and test ordering
• Improve quality of care
– Application of Clinical Pathways and Guidelines
– Evidence based Medicine
– Improved Clinical documentation
– Increase quality time for direct patient care
• Improve efficiency in Healthcare delivery
– Reduce costs, reduce test duplication, decrease
adverse events
61
62. CDSS:
Computerized Physician Order Entry
• Growing evidence that CPOE reduce medical
errors and adverse drug events.
Effects of Computerized Physician Order Entry and Clinical Decision Support
Systems on Medication Safety Rainu Kaushal,MD,MPH et al Arch Intern
Med. 2003
http://archinte.ama-assn.org/cgi/content/full/163/12/1409
Effects of Computerized Clinical Decision Support Systems on Practitioner Performance
and Patient Outcomes
Garg et al JAMA. 2005
http://jama.ama-assn.org/cgi/content/full/293/10/1223
62
63. Opposing views…
• CPOE facilitate medication error ‘risks’, create new
errors.
Role of Computerized Physician Order Entry Systems in Facilitating Medication
Errors. Ross Koppel,PhD et al. JAMA. 2005
http://jama.ama-assn.org/cgi/content/full/293/10/1197
Computer Technology and Clinical Work Robert L. Wears et. al.
JAMA. 2005;293:1261-1263
.
http://jama.ama-assn.org/cgi/content/full/293/10/1261
63
66. CDSS TYPES based on their USAGE
• Knowledge-based systems
Alerts and reminders (in real-time)
Diagnostic assistance (some with likelihood input)
Therapy critiquing, interactions and planning
Prescribing decision support systems
Information retrieval (selects best resource)
Image recognition and interpretation
Early warning systems
• Expert laboratory information systems (Interpretation)
• Machine learning systems (futuristic learning expert
system)
67. Point of Care Clinical Resources: Decision Tools
• Isabel:
http://www.isabelhealthcare.com/home/defa
ult
•Open Clinical:
http://www.openclinical.org/dss.html
• DXplain:
http://dxplain.org/dxp/dxp.pl
Calculators, Conversions and Scoring Tools
Skyscape:
http://www.skyscape.com/Windows/Archime
des360BySpecialty.aspx
•Emergency Medicine on the Web: Best
viewed on Internet Explorer not Google
Chrome.
http://www.ncemi.org/
MedicineWorld.Org:
http://medicineworld.org/online-medicalcalculators.html
•Clinical Decision Making Calculators:
http://www.fammed.ouhsc.edu/robhamm/cd
mcalc.htm
68. Types of Calculators
• Medical equation calculations
– i.e. body mass index, dosage calculator, unit
converter – emphasis Patient Safety
– Largely free online and for PDA
• MedMath and MedCalc
• Clinical rules, decision trees or criteria
calculators
– i.e. Ottowa ankle rule, NIH Stroke Score,
diagnostic likelihood calculator, mortality
calculator, CURb-65, Killip Class, Ranson’s, APGAR
et
Session 5
68
73. The ATHENA/EON
Hypertension-Management SystSoftware to aid clinical decision-making; characteristics of patient are matched to knowledge base,
recommendations are presented to the clinician/patient
(Sim et al, JAMIA, 2001)
76. Point of Care Clinical Resources: Patient Education
WebMD:
http://www.webmd.com/
PubMed Health:
http://www.ncbi.nlm.nih.gov/pubmedhealth/s/
diseases_and_conditions/a/
MedlinePlus:
http://www.nlm.nih.gov/medlineplus/
NHS Choices:
http://www.nhs.uk/Conditions/Pages/hub.aspx
The NNT:
•http://www.medicine.ox.ac.uk/bandolier/ban
d50/b50-8.html
•http://www.thennt.com/
•http://www.nntonline.net/visualrx/v3/display.
aspx
King Abdullah Encyclopedia:
http://www.kaahe.org/ar/
77. • WebMD Mobile
WebMD Mobile provides consumers with reliable,
timely, and accurate health information on the go. It
includes the award-winning WebMD Symptom
Checker, a comprehensive drug, supplement and
vitamin treatment database, as well as essential first
aid information.http://www.webmd.com/
• MedlinePlus
MedlinePlus is the National Institutes of Health's Web
site for patients and their families. Produced by the
National Library of Medicine, it brings information
about diseases, conditions, and wellness issues in lay
language.
78. • drawMD is a free app for the iPad to enhance doctor-patient
communication by offering interactive visual guides as a tool for explaining
complex issues and possible medical and surgical solutions.
• Select one of the detailed anatomic images from the 10 medical
specialties or upload your own, and then sketch, stamp, or type directly on
the images. Â The images and stamps are tailored to each specialty and
allow you to explain treatments and procedures in a personalized, easily
understood way. Then, share those images and notes with the patient and
retain them as a record of the consultation.
• With drawMD, patients better understand  conditions and procedures,
while the time required for the consultation is reduced. Simple, visuallyoriented consultations are more understandable for patients, and can
provide the context that is used to improve and engagement and
satisfaction.
• More information about the app is available
fromhttp://www.drawmd.com/. The app is available for download from
the AppStore.
81. Patient-Centered Shared Decision Making
Mayo Clinic:
http://shareddecisions.mayoclinic.org/
Diabetes:
http://shareddecisions.mayoclinic.org/files/2011/08/Diabetes_Medication_Cho
ice.pdf
Patient Decision Aids
http://decisionaid.ohri.ca/AZlist.html
82. Shared Decision Making Resources
• DHMC Center for Shared Decision Making
– http://www.dhmc.org/dept/csdm
• Ottawa Health Research Institute
– http://decisionaid.ohri.ca/index.html
• Healthwise Preferred Care
– http://www.healthwise.net/preferredcare
• WebMD
– http://www.webmd.com/
• Foundation for Informed Medical Decision Making
– http://www.informedmedicaldecisions.org
• Health News Review
– http://www.healthnewsreview.org
83. Use of DDx Tools with Students
• During presentation of Patient with acute
problem
• Ask student for DDx
• Tell student to use DxPlain, Epocrates Sx,
which they have, or PEPID and name other
possibilities
Session 4
83
83
84. SOFTWARE PUBLISHERS
•
•
•
•
•
Apps for Healthcare Professionals Collection
Apple's App Store has put together a collection to make it easier for healthcare
professionals to find apps for their mobile devices. It includes six categories:
reference apps, educational apps, EMR & patient monitoring apps, imaging apps,
point of care apps, and personal care apps (which is actually aimed for consumers.)
See the link above for a review by iMedicalApps.
Medical Wizards
Software for medical professionals by medical professionals. Not free.
QxMD
Authored by clinician experts, QxMD’s authoritative free and inexpensive mobile
apps are relied upon by physicians, nurses and other health care professionals.
Skyscape - 25% discount
- Skyscape offers medical references for mobile devices.
- Available for Windows Mobile, Palm, iPhone, BlackBerry, Android.
- In collaboration with the University of Calgary Libraries, Skyscape now offers a
25% discount on the purchase of Skyscape resources for mobile devices.
Unbound Medicine
Unbound Medicine offers medical references for purchase for mobile devices.
DIAGNOSTIC TOOLSUse DxPlain: This is Rocky Mountain Spotted Fever. It is a Rare disease. Therefore, it won’t be under the common problems. It will show up as highly likely with ++ PEPID only takes: Headache, severe; palmar erythema; skin rashes, erythematous, maculopapular; muscle pain (instead of myalgia) malaise and tick bite. Adding others confuses it. Exercises for Practice should be used as examples for Demo. Start demoing when you get to these slides. You can say something like “let’s work this exercise together…” and On your computer, you would go to ….. If you let them look this up first then show them how, you won’t make it thru all the content.