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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
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Major Competency
Students will• Demonstrate the ability to acquire new data
and information and to critically appraise its validity and applicability.
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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]
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Resources
http://www.med.fsu.edu/informatics/ Medical References
• PowerPoint
• Assessing the Validity of Online Medical Information
• Decision Support
• Using Drug Resources
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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
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In the Beginning…
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Journals
Text Books Drug Info
Pocket Manuals
Note CardsPeer Reviewed
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“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.
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Note Cards
Journals
Text Books Drug Info
Pocket Manuals
21st Century Medical Information
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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?
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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
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Assessing the Validity of Information on the Web Site ownership/domain
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• Gov– CDC– AHRQ– NLM.NIH– DHHS– FDA– States fl.us
• Edu– Medical Centers
• Org– Associations
• AAFP
• ACP
• ACOG
– Disease orgs• ADA
• ALA
• Com– Commercial
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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
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Wikipedia
List 5 ways Wikipedia does not fit the criteria as a reliable site.
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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
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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
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Assessing the Validity of Information on the Web Library subscription resource = reliable
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Be Skeptical
You will be taught the principles of critical review of the literature in your
second year along with Evidence Based Medicine (EBM)
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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?
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Answering a Background Question
Searching most efficient Google/Wikipedia (assess the validity) Use Medical Dictionary Basic Science Textbooks
• Access Medicine
• Thieme
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Searching with Google
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Web Based Medical Information
Google Search
Free
$ubscription
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Your eBookshelf
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Medical Dictionaries
Stedman’s is at eMedicine, in PEPID Dorland’s at Merck
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Using Stedman’s Medical Dictionary• eMedicine online
• PEPID online and PDA
Look up:
dyspnea nephrolithiasis
teratogenic iatrogenic
epistaxis
cyanosis
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Exercises for PracticeExercises for Practice
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Books on the Library Web Page
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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
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WebFeat Search
Searches Library Resources Pick the type of resources to
search Groups by resource Uses resource search engine
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New Website Searches
Multi-Search = Webfeat
Changing to SerialSolutions 360, August 2010
Only eBooks and Patient Education
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Access Medicine
Best selection of all basic science books Combined with good clinical medicine
books Search productive
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Answering Clinical Questions
At the Point of Care
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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
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Current Library Web Site (Sum 2010)
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New Library Webpage
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Access Issues
IP address verification Limited simultaneous users Special URL issues Bottom Line
• Use links on Library Homepage
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Off Campus Access
IP authentication Proxy server – EZProxy FSU COM ID and password Use links on library page
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Current Site - New Site
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Primary Resources of the Maguire Medical Library
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Differential Diagnosis Tools
DxPlain
PEPID
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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)
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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
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Drug Information
Epocrates Online
PEPID
Harrison’s Practice
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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
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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
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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
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PEPID Drug Interaction Tool
Select all drugs on list
Say Done Click Interactions Click specific
interaction to read details
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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?
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Disease Quick References
DynaMed (Web and PDA)
eMedicine (Web and PDA)
Harrison’s Practice (Web and PDA)Epocrates Dx
PEPID
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Types of Questions Best Answered by Disease Quick References
Description/background Epidemiology Diagnosis Treatment Ongoing management Prognosis/outcomes Prevention
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Bottom Line
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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
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PDA and Online
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DynaMed
Organization: Includes History and
Physical sections (why am I asking these questions)
Expand or collapse sections
Use CTRL-F to search page
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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
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Exercises for PracticeExercises for Practice
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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
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Use FireFox
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eMedicine Monographs
Subscription eliminates ads found on free Medscape site
One long page of information Navigation clunky, inconsistent
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CTRL-F
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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
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Exercises for PracticeExercises for Practice
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Harrison’s Practice
Internal Medicine focus Linked to Access
Medicine content Has drug information from
GoldStandard Nice navigation on left
side
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PDA and Online
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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
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Exercises for PracticeExercises for Practice
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Top 10 Chief Concerns
1. Cough2. Fatigue3. Low Back Pain4. Fever5. Dyspnea
6. Generalized Abdominal Pain
7. Headache8. Vertigo9. Chest Pain10. Edema
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Ponka, D., et al. Top Ten Differential Diagnoses in Primary Care. [Web Resource] U of Ottowa. 2006. Accessed at www.familymedicine.uottawa.ca/
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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
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Recorded by FSU CoM Students in 3rd year Clerkships
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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
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PDAs to be distributed in August 25-27
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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
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