Online clinical support: Medical information at your fingertips
In this month’s article, we take a look at the many online and mobile resources that help us provide our patients with the best care.
There was a time not that long ago when, if we had a patient care question, we’d simply pull a book off the bookshelf, locate the appropriate topic, and find the solution to our clinical conundrum. For the majority of questions arising in routine clinical practice, this process would prove more than adequate. Rarely, when we were stumped and desperate, we would “phone a friend,” usually a pediatric specialist who would provide useful advice for managing our complicated patient.
Times have changed a bit, and between trying to see all our patients and completing our electronic health care record (EHR) charting, pediatricians have little extra time to devote to researching clinical questions. Another obstacle to providing the most up-to-date care is that many busy pediatricians find it difficult to keep up with the current pediatric literature and may not be familiar with the latest evidence-based practice guidelines and recommendations.
Unless you’re a recent graduate, much of the “stuff” we learned in medical school and residency has become outdated, and we must continue to reeducate ourselves regarding appropriate workup and management of routine issues. While I try to learn just 1 new thing every day I’m in practice, I’m sure there are many conditions I see so infrequently that they are no more than distant memories. In this month’s Pediatrics V2.0 article, we’ll look at the many online and mobile resources that help pediatricians provide our patients with the best care.
A typical pediatrician keeps copies of 2 resource texts always close at hand. These would be the Harriet Lane Handbook: A Manual for Pediatric House Officers (now in its 19th edition) and the American Academy of Pediatrics (AAP) Red Book Atlas of Pediatric Infectious Diseases (aka, the Red Book) with the latest edition published in 2012. These trusted resources have helped pediatricians care for generations of infants and children.
The Harriet Lane Handbook provides a quick resource for drug dosages and normal lab values, and the book is also great at guiding workups for common clinical issues such as hematuria, anemia, goiter, limp, and innumerable other problems. For an infectious disease and immunization reference, there has never been a more thorough and comprehensive resource than the Red Book.
I would also add to this list of handy books our favorite pediatric textbook. For most of us, this would likely be the Nelson Textbook of Pediatrics, although the AAP Textbook of Pediatric Care is a close rival. Reading sections of either textbook in the context of a clinical case provides a welcome review while providing guidance and direction for patient management.
There are electronic versions of these resources, of course, that often offer additional features, quick navigation, and enhancements. For example, the online version of the Red Book features an extensive visual library illustrating examples of many conditions discussed in the text as well as infectious disease-related news items. Tablet versions of these resources are also availabley. One can get the Red Book and the Textbook of Pediatric Care directly from the AAP online bookstore as e-books, and both the Harriet Lane Handbook and Nelson Textbook of Pediatrics are available if you subscribe to MD Consult from Elsevier. Note that the AAP’s Textbook of Pediatric Care can be accessed for free by subscribing to Pediatric Care Online.
Call me old fashioned, but I’ve been using the real world texts for so many years that I will likely never give up the bound versions of these resources. However, if clinical questions come up when I round at the hospital, when I’m in an exam room with a patient, or when I am on call at home, clinical information is always just a personal computer or smart device-connection away.
Clinical knowledge support systems
When time permits, I review additional information from several clinical knowledge support systems as well. Reading recommendations from a number of sources always gives me confidence that I am using the best clinical-care strategies for my patients. In comparison to online versions of trusted pediatric reference textbooks and manuals, many physicians nowadays utilize 1 or more online clinical knowledge support systems.
I depend almost exclusively on 2 reliable online resources to complement my textbook resources. I would speculate that most physicians are familiar with the UpToDate subscription service. Priced at a reasonable $500 per year, UpToDate provides an expansive catalog of disease conditions that can help expedite diagnosis and treatment. One merely enters the symptom or diagnosis and the search yields appropriate items for review. References to clinical studies supporting the authors’ recommendations are plentiful, and diagnosis is usually cross-referenced to related topics in the database. All topics are reviewed and updated by section editors on a regular basis, so you can be assured that information is current. I recently found the section on idiopathic thrombocytopenic purpura (ITP) very helpful in managing a patient. Algorithms, photos, and illustrations are often provided and frequently can facilitate a workup even if you don’t have time to read through the discussion. Additionally, educational materials are available for a limited number of disease conditions allowing you to share information with your patients when appropriate.
The free alternative to UpToDate is eMedicine, now an online service provided by Medscape. Originally conceived in 1996 as an online emergency medicine textbook, the service grew rapidly and became a resource trusted by clinicians. A search entry is entered and then one can quickly drill down to the appropriate sections. Topics are organized into Overview, Presentation, Differential Diagnosis, Workup, Treatment, and Medication, with subsections for each topic. The organization makes it quite easy to focus on the section you need (eg, medication) while ignoring unneeded material. The eMedicine sections also include a multimedia library with illustrations, charts, and photos. Patient handouts are not available, but eMedicine integrates nicely with WebMD’s Medscape News and Reference resources and provides lots of free continuing medical education material covering a wide range of topics.
While UpToDate and Medscape’s eMedicine are my personal favorites, competition is fierce between online medical resource providers. DynaMed from EBSCO features a spartan, uncluttered interface and is priced right at $400 per year. The AAP’s version of a clinical knowledge support system is Pediatric Care Online, which costs $259 for AAP members. Information supplied by Pediatric Care Online is nicely summarized and organized with information presented from AAP policy statements, the Red Book, or the Textbook of Pediatric Care. Pediatric Care Online also has a multimedia library and displays current AAP news in addition to a wide variety of clinical support tools and the complete AAP library of patient handouts. The feature set is great and the tablet version is extremely easy to navigate (the Textbook of Pediatric Care is only available to read with the online version, however). The last Web site I would recommend bookmarking is Merck Medicus, a free clinical support service, with information presented largely from the current edition of the Merck Manual. Patient information handouts are available for free.
Note that these services provide detailed summaries of medical conditions and appropriate references for all their recommendations. One can use other services such as $500-per-year MD Consult (soon to be replaced by Elsevier’s new service called ClinicalKey), to read references, if you have an interest.
Parents are becoming experts
One situation that we did not face in the pre-Internet days is concerned parents who have a wealth of resources available to them on the Web. It is not uncommon for parents to research a subject and come in with a laundry list of questions and their own requests for tests they’d like performed and specialists they’d like to see. If possible, it is always prudent to steer patients toward trusted resources such as those provided by the AAP or the Centers for Disease Control and Prevention (CDC). The AAP's free site for patient information, HealthyChildren.org, provides thorough discussions of dozens of common preventive care and common acute illness conditions. In addition, the CDC’s site has an incredibly extensive library of diseases and conditions. Even Wikipedia usually provides accurate information and is a resource with which most parents are familiar.
As discussed previously in the Pediatrics V2.0 series, your practice’s patient portal should include access to information sheets regarding many common pediatric problems, and this should be promoted as your patient’s parents’ home base for information. When you’d like to maintain a digital library of handouts that can be printed and handed to parents, you can subscribe to either Pediatric Care Online (above) or to the AAP Patient Education Online service ($225 per year for members).
Are there new guidelines for this?
It seems that every time you pick up a pediatric journal you discover new guidelines for common pediatric illnesses (vision screening, Clostridium difficile infections, otitis media with effusion, sinusitis, gonorrhea, and more) and not all new guidelines originate from the AAP. Pediatricians can review AAP guidelines via its Web site’s section on policy, but the best resource for discovering if a new guideline or policy has been issued by any organization while you were sleeping is to visit guidelines.gov. Input a search item and, voila, any policies or guidelines will appear for review.
The future: clinical decision support systems
While the above resources are currently more than adequate for providing helpful patient management information that is merely a mouse click or a finger tap away, health care information technology experts expect that our EHRs will eventually be augmented with clinical decision support systems. Using complex algorithms, software integrated into “approved” EHRs will facilitate diagnosis by examining a patient’s symptoms and signs and will suggest a diagnosis and appropriate workup. Many such support systems are currently available and being tested at academic health care facilities around the country.
A good example of a clinical decision support system is VisualDX, available for just $99 per year for pediatricians. VisualDX is designed to help pediatricians identify rashes associated with a variety of clinical conditions. Unlike clinical knowledge support systems, where one inputs a diagnosis to retrieve information, with VisualDX one inputs symptoms or clinical findings and the online system presents a list of diagnoses (all associated with rashes) to assist with your diagnosis. A tablet version of VisualDX is available as well. Note that a rudimentary version of a clinical decision support system is available via the Pediatric Care Online Web site as a “signs and symptoms” input tool. As the name suggests, you input descriptive phrases such as “fever,” “rash,” or, “arthralgia” and the online tool suggests possible diagnoses and provides resources to review.
At this point, I remain a bit skeptical about clinical decision support systems. Although I don’t mind a little help doing my job, I continue to believe that medicine is often more art than science, and my gut feelings and intuition have over years proven themselves invaluable with patient care. These clinical skills will never (hopefully) be replicated in software.
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