Point of Care Decision Support Resources [online and mobile]

1. Point of CareDecision Support Resources[online and mobile] , MD, Regional Campus Informatics Director Nancy Clark, M.Ed., Director of Medical Informatics Education

2. Objectives • Identify useful Library resources to answer clinical questions quickly – select favorites • 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 and patients 2 Session 4

3. Handouts • PowerPoint • Decision Support Handout • Evaluation • Using Resources with Students • List of Free or Cheap Medical Apps 3 Session 4

4. New Library Webpage (Fall 2010) • Prototype at • http://dev.cimes.fsu.edu/fsucom/prototype/

5. POC Decision Support Tools

6. EZProxy Reminder • Off campus: Log into EZProxy with CoM username and password • Use library page links to access online resources firstname.lastname $fsumed$xxxx Intro to Medical Library Resources

7. Mobile Device Versions Available

8. Resource Content

10. PEPID

11. PEPID Online/Mobile • Contents: • Clinical rotations (Peds, Surg, IM, etc.) • Calculators • DDx Generator • Disease reference • Drug information and interaction tool • Lab Manual • Stedman’s Dictionary • Illustrations (anatomy, EKG strips, etc.) • Procedures Session 5

12. PEPID on the PDA • 100% of content on web • Links between diseases, drugs, images and calculators.

13. PEPID CRC Disease • Web and PDA (iPhone, iPad, Android, and Blackberry) • 2,700 Disease and Trauma topics with diagnosis, pathophysiology, treatment and disposition

14. PEPID Disease Content • Diseases info broken down into Diagnosis and Treatment

15. Exercises for Practice • Which drugs are not effective, and possibly harmful for patients with PTSD? • What drugs can cause drug related headaches? • What is the best treatment for analgesic rebound headache?

16. PEPID Calculators • Both medical equations and “Scores” • Online and PDA same instruments Session 5

17. PEPID Calculators PDA • Under Table of Contents • Or Search for desired calculator (BMI, IADL, etc.) • Alphabetical List or by category • Icon in text Session 5

18. Exercises for Practice • 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? Session 5

19. PEPID Lab Manual Session 5

20. Exercises for Practice • 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? Session 5

21. PEPID DDX • Enter symptoms, exam, labs • DDx nicely numbered as to likelihood • Linked to disease info for more information Seminar 4Session 4

22. Exercises for Practice • A 32 year old female presents to you complaining of off and on blurry vision in right eye (vision, loss, one eye) and intermittent eye pain, tingling on right side of face (paresthesia), Leg cramping (usually calf muscle at night), fatigue and constipation (chronic). Examination and questioning reveals that she has had some double vision, and her eyes are moving involuntarily back and forth (nystagmus).

23. Use of DDx Tools with Students • During presentation of Patient with acute problem • Ask student for DDx • Tell student to use DxPlain or PEPID and name other possibilities 23 Session 4

24. DxPlain

25. Diagnostic Tools • Enter symptom(s), findings, and labs • Get a differential in order of likelihood • Get more info on disease • Get advice on more symptoms to look for • Get advice on labs to order 25 Session 4

26. DxPlain • Very powerful expert system • From Harvard • Age, gender and duration • Allows for multiple symptoms and lab results • Get Dx information 26 Session 4

27. 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?

28. *PDA Only Epocrates New iPad version released 11/12/12

29. Epocrates Diseases • Content from BMJ • Linked drugs to drug monographs • Linked from Lab to diseases • Excellent Interface • Images • More detail online than on mobile version 29 Session 4

30. Exercises for Practice • What is the incidence and prevalence of Rocky Mountain Spotted Fever in the US? • What is the treatment of choice and dosage for RMSF? • What medication should be used to treat RMSF during 1st trimester of pregnancy?

31. MedCalc on Epocrates Online • Online version is better than PDA version • MedCalc3000 (medcalc3000.com) • Extensive medical calculators and clinical rules, decision trees • Organized by specialty or alphabetical Session 5

32. 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 Session 5

33. Epocrates Online Clinical Criteria Session 5

34. MedCalc3000 Calculators • Also available online in • Dynamed • Facts and Comparisons

35. Exercises for Practice • What is the predicted peak flow for a 60 year old woman with asthma? She is 5’2”. • 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

36. MedMath in Epocrates PDA • Does not have same calculators as Epocrates Online. • Few basic calculators • Pick Calculator or type in Search box. Session 5

37. Exercises for Practice • 81 year old female with long standing diabetes, and hypertension. Her BP is usually 140-150/85-90. Her ideal body weight is 112 lb. Laboratory tests: serum creatinine 1.2mg/dl, Hgb A1C 7.8, liver function tests normal. What is her creatinine clearance? • Your DKA patient in the ICU has Na+ 133, glucose 785. You remember that hyperglycemia throws off the Na+. What is the real, corrected Na+? Session 5

38. Epocrates Essentials Lab on PDA • Labs only • Interpretation linked to Rx and Dx sections • Search or • Browse Panels or Specimen type Session 5

39. 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? • What ICD-9 codes might get you authorized and/or paid to order an RF? Session 5

40. Dynamed

41. DynaMed • Combines summary of topics with latest evidence/lit updates on topic • Links out to articles and reviews if more details needed – run PubMed first, minimize • Updated constantly (more up to date than UpToDate) PDA and Online 41 Session 4

42. Dynamed Most Current Dx Resource Banzi R, Cinquini M, Liberati A, et al. Speed of updating online evidence based point of care summaries: prospective cohort analysis. BMJ. 2011;343:d5856.

43. DynaMed Organization of Results • Description (including ICD-9 Codes) • Description, Also called, ICD-9 Codes, Types, Organs Involved, Who Is Most Affected, Incidence/Prevalence • Causes and Risk Factors • Causes, Pathogenesis, Likely risk factors, Possible risk factors • Complications and Associated Conditions • History • CC, HPI, Meds, PMH, FH, SH, ROS • Physical • Skin, HEENT, Neck, Extremities, Neuro, Pelvic • Diagnosis • Making the diagnosis, Rule out, Tests to order, Blood tests, Urine studies, Imaging studies, Pathology tests, Other diagnostic testing • Prognosis • Treatment • Treatment Overview, Diet, Activity, Counseling, Medications, Surgery, Consultation and referral, Other management, Follow-up • Prevention and Screening • References (including Reviews and Guidelines) • Patient Information 43 Session 4

44. DynaMed Mobile • In Skyscape Medical References • Complete disease content of web site • Free to faculty and students • iPad easier to use. Lots of scrolling on small screen • Linking out only works if wireless • iPad, iPhone, Blackberry, Android versions 44 Session 4

45. Exercises for Practice • A 65 year old Jewish 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?

46. Calculators in Dynamed • Online Medcalc 3000 (same as Epocrates Online) • On the PDA, Archimedes free with Skyscape

47. Exercises for Practice • You have a pancreatitis pt in the ICU and know he may be quite sick. That is his Ranson’s Criteria score and his mortality risk? On admission: age 61, wbc 19k, glucose 211, LDH 274, AST 199. Within 48 hrs: hct fall 7%, BUN up by 11, Ca 1.1 mmol/L, PaO2 74, base deficit 3 mEq/L, 3rd spacing 8 liters thus far.

48. uCentral: Diagnosaurus, 5 Minute Clinical Consult, etc.

49. U Central Resources • Clinical Evidence • Diagnosaurus • Harrison’s Manual • Washington Manual • 5 Minute Clinical Consult (5MCC) • Johns Hopkins ABX, DM, and HIV Guides • MEDLINE search

50. Diagnosaurus • DDX tool • Look up a symptom or presenting problem • Get a list of possible diagnoses • Linked to content in 5MCC