Finding Reliable Clinical Information Online

Nancy Clark, M.Ed.Director of Medical Informatics Education

FSU College of Medicine

Summer 2010 1

An Introduction

http://www.med.fsu.edu/informatics/MedicalReferences.asp

Major Competency

Students will• Demonstrate the ability to acquire new data

and information and to critically appraise its validity and applicability.

Summer 2010 2

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 2010 3

Resources

http://www.med.fsu.edu/informatics/ Medical References

• PowerPoint

• Assessing the Validity of Online Medical Information

• Decision Support

• Using Drug Resources

Summer 2010 4

Review

What is the most efficient, unbiased way to keep up to date?1. Go to conferences

2. Read 20-30 journal articles a week

3. Look up answers to clinical questions when they occur in a reliable, current resource

Summer 2010 5

In the Beginning…

Summer 2010 6

Journals

Text Books Drug Info

Pocket Manuals

Note CardsPeer 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, MDPioneer of Evidence Based Medicine (EBM)

Summer 2010 7

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

Note Cards

Journals

Text Books Drug Info

Pocket Manuals

21st Century Medical Information

Summer 2010 8

Here is the Problem…

Summer 2010 9

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

Health on the Net Code of Conduct HON

Assessing the Validity of Information on the Web

Summer 2010 10

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

Summer 2010 11

• Gov– CDC– AHRQ– NLM.NIH– DHHS– FDA– 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 2010 12

Wikipedia

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

Summer 2010 13

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 2010 14

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 2010 15

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

Summer 2010 16

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 2010 17

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 2010 18

Answering a Background Question

Searching most efficient Google/Wikipedia (assess the validity) Use Medical Dictionary Basic Science Textbooks

• Access Medicine

• Thieme

Summer 2010 19

Searching with Google

Summer 2010 20

Web Based Medical Information

Google Search

Free

$ubscription

Your eBookshelf

Summer 2010 21

Medical Dictionaries

Stedman’s is at eMedicine, in PEPID Dorland’s at Merck

Summer 2010 22

Using Stedman’s Medical Dictionary• eMedicine online

• PEPID online and PDA

Look up:

dyspnea nephrolithiasis

teratogenic iatrogenic

epistaxis

cyanosis

Summer 2010 23

Exercises for PracticeExercises for Practice

Books on the Library Web Page

Summer 2010 24

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 2010 25

WebFeat Search

Searches Library Resources Pick the type of resources to

search Groups by resource Uses resource search engine

Summer 2010 26

New Website Searches

Multi-Search = Webfeat

Changing to SerialSolutions 360, August 2010

Only eBooks and Patient Education

Summer 2010 27

Access Medicine

Best selection of all basic science books Combined with good clinical medicine

books Search productive

Summer 2010 28

Answering Clinical Questions

At the Point of Care

Summer 2010 29

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)

Learn to use subscription resources

Summer 2010 30

Current Library Web Site (Sum 2010)

Summer 2010 31

New Library Webpage

Summer 2010 32

Access Issues

IP address verification Limited simultaneous users Special URL issues Bottom Line

• Use links on Library Homepage

Summer 2010 33

Off Campus Access

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

Summer 2010 34

Current Site - New Site

Summer 2010 35

Primary Resources of the Maguire Medical Library

Summer 2010 36

Summer 2010 37

Differential Diagnosis Tools

DxPlain

PEPID

Summer 2010 38

Differential Diagnosis Tools

Enter symptoms or chief complaint• Get a differential

• Get more info on disease

DxPlain *****• Harvard

• Allows for multiple symptoms and lab results

• Drawback: Slow

PEPID ***• Multiple symptoms

• Lab Results

• Age, gender, duration eMedicine ** Access Medicine’s

• Diagnosaurus* (DDX tab)

Summer 2010 39

Summer 2010 40

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 PracticeExercises for Practice

Drug Information

Epocrates Online

PEPID

Harrison’s Practice

Summer 2010 41

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 2010 42

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 2010 44

PEPID Drug Interaction Tool

Select all drugs on list

Say Done Click Interactions Click specific

interaction to read details

Summer 2010 45

Exercises for PracticeExercises 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 2010 46

Disease Quick References

DynaMed (Web and PDA)

eMedicine (Web and PDA)

Harrison’s Practice (Web and PDA)Epocrates Dx

PEPID

Summer 2010 47

Types of Questions Best Answered by Disease Quick References

Description/background Epidemiology Diagnosis Treatment Ongoing management Prognosis/outcomes Prevention

Summer 2010 48

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 2010 49

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 2010 50

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 2010 51

Exercises for PracticeExercises 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 2010 52

Use FireFox

eMedicine Monographs

Subscription eliminates ads found on free Medscape site

One long page of information Navigation clunky, inconsistent

Summer 2010 53

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 2010 54

Exercises for PracticeExercises for Practice

Harrison’s Practice

Internal Medicine focus Linked to Access

Medicine content Has drug information from

GoldStandard Nice navigation on left

side

Summer 2010 55

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 2010 56

Exercises for PracticeExercises for Practice

Top 10 Chief Concerns

1. Cough2. Fatigue3. Low Back Pain4. Fever5. Dyspnea

6. Generalized Abdominal Pain

7. Headache8. Vertigo9. Chest Pain10. Edema

Summer 2010 57

Ponka, D., et al. Top Ten Differential Diagnoses in Primary Care. [Web Resource] U of Ottowa. 2006. Accessed at www.familymedicine.uottawa.ca/

Top 20 Diseases

1. Hypertension 11. Obesity

2. Depression 12. Gall Bladder disease

3. Hyperlipidemia 13. GERD

4. Diabetes Type 2 14. Asthma

5. Bipolar disorder 15. Sinusitis

6. Anxiety disorder 16. Substance abuse

7. Cold/URI 17. COPD

8. ADHD 18. Coronary Artery Disease

9. Otitis media 19. Peripheral vascular disease

10. Schizophrenia 20. Pneumonia

Summer 2010 58

Recorded by FSU CoM Students in 3rd 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 2010 59

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 2010 60