This newsletter is approved for 1 hour of AOA Category 1-B CME credit by the AOA CCME. See quiz.
Volume 1, Number 5
Summer/Fall 2014
In this Issue:
“Introduction”
“What is Internet PoC”
“What is Evidence-Based Medicine”
“What is Healthy People 2020”
“Checklist for Implementing PoC in your Practice
“Meet your LMU-DCOM Medical Librarians”
“Tips for Searching the Literature”
“Key Points”
“Suggested Reading and Resources”
Page 1
Page 2
Page 3
Page 4
Page 5
Page 6
Page 6-7
Page 8
Page 9-10
Internet Point of Care (PoC)
Introduction
In this issue, we highlight the use of a self-directed, online learning CME activity (Internet
PoC) for appointed clinical adjunct faculty and PoC’s role in translating new knowledge into
practice and improving patient care (Figure 1). One of the long-term goals is achieving Healthy
People 2020 goals which represents the highest level of population health.
A brief discussion of Internet PoC, Evidence-Based Medicine (EBM), and Healthy People 2020
is presented to introduce the connection to the CME
activity format and as a faculty development tool for
PoC. A checklist of the Internet PoC activity provides an
easy-to-use guide in implementing the CME activity in
your practice, patient care, and potential impact on
Improved
Patient
HealthyPeople2020.
Finally, the role of medical librarians and Health
Information Technology (HIT) on the CME team, an
essential part of PoC learning, is discussed; providing a
valuable resource for clinical care decisions.
The Preceptor Vol 1; No 5
PoC
Knowledge
to Practice
(EBM)
care
Figure 1
1
What is Internet Point-of-Care (PoC)
Internet point of care (PoC) CME describes structured, self-directed, online learning by
physicians on topics relevant to their clinical practice. Learning for this activity is driven by
a reflective process in which physicians must document their clinical questions, the sources
consulted, and the application to practice. (Wentz, D. Continuing Medical Education:
Looking Back, Planning Ahead)
The goal of Internet PoC is to enhance physician’s knowledge, competence, and performance that
can be applied to their practice with a desired outcome of better health care outcomes for their
patients and, hence, to improve population health (Healthy People 2020). Internet PoC meets
desired CME and life-long learning needs through adult learning principles where physician
learning is active rather than passive, and most successful when placed in the context of relevant
patient care, physician’s self-direction and self-assessment, and reflective practice.
To meet Internet PoC criteria for CME, the process must include the following (adapted from The
Physician’s Recognition Award and Credit System, 2010 rev):
1. Have an established process for the accredited CME provider to oversee content integrity,
with responsibilities that include, but are not limited to, the appropriate selection and use of
professional, peer-reviewed literature, and ensuring that search algorithms are unbiased.
2. Provide clear instructions to the physician on how to 1) access the portal, database, which
databases have been vetted for use, 2) how participation will be tracked and, 3) how the
accredited CME provider will award credit.
3. Verify physician participation by tracking the topics and sources searched.
4. Implement reasonable safeguards to assure appropriate use of this information.
5. Provide a procedure by which physicians can give feedback on overall system effectiveness.
6. Establish a procedure by which physicians may claim CME Credit, by completing
and documenting the required three-step cycle:
a. Review original clinical question(s).
b. Identify the relevant sources from among those consulted.
c. Describe the application of their findings to practice and whether it resulted in a change
in knowledge, competence or performance as measured by physician practice application
or patient health status improvement.
The Preceptor Vol 1; No 5
2
What is Evidence-Based Medicine (EBM)
History of EBM
One of the earliest and most widely-accepted definitions of evidence-based medicine (EBM)
comes from a 1996 article by David L. Sackett. The article states that EBM is “the
conscientious, explicit, and judicious use of current best evidence in making decisions about
the care of individual patients.”1 Though many physicians practiced variations of evidencebased medicine before this, the literature on and interest in the concept exploded in the early
1990s and continues to this day.
The EBM Process as it Relates to Point of Care
Point of Care emphasizes active learning on the part of the physician. Though EBM relies on
literature for evidence, it also requires that a physician has the skills necessary to search for,
aquire, assess, and apply appropriate evidence based literature to his or her practice. In
order to apply EBM to practice through active learning, physicians may consider following the
five to six step process, abbreviated by the accroynm 5A+E.
5A+E stands for ask, acquire, appraise, apply, assess, and evaluate.2 Practicioners of EBM must
ask answerable questions clearly in order to search for responses efficiently. One method of
asking questions is to plot them according to the PICO(T) model, which outlines
population/patient, intervention, comparisons, and outcomes.3 (For more information about
PICO(T) see the “Tips for Searching the Literature” section of this newsletter.) Next, providers
must search for evidance according to their questions. This can be done in a variety of
databases with the assistance of librarians, if desired. After aquiring literature, the physician
or health care provider must assess the validity of the articles and their usefulness to
answering his or her question. Once recommendations from the literature are considered
valid and useful, they are applied to practice. Finally, physicians and other practicioners must
assess the outcomes of applied evidence to confirm any benefits or drawbacks to their
changes in practice.
Criticism
Without research and evidence to support treatments, physicians could run the risk of
injuring patients or providing them with ineffective remedies. Because of this, awareness of
evidence from current relevant literature is important; however, it is also recommended that
physicians use expert opinion in order to inform their appraisal of literature and evidence.4
Some concerns regarding EBM lie in criticisms of the literature from which evidence is
retrieved. With the rise and acceptance of EBM came companies, primarily pharmeceutical,
who published research that promoted their products.5 As many pharmeceutical companies
have the necessary funds to experiment, perform trials, and publish, this has led to a bias in a
portion of the literature from which evidence could be drawn.6,7 This results in a critical need
to examine and consider author bias and funding sources when exploring literature. In order
to facilitate this, better assessment tools and more independent and unbiased research is
called for by those critiquing EBM.8,9
The Preceptor Vol 1; No 5
3
What is Healthy People 2020
Healthy People 2020, the product of an extensive Figure 2
Health People 2020
stakeholder driven process, is an ambitious, yet achievable,
Leading Health Indicator Topics
10-year agenda for improving the Nation’s health. For the
past 30 years, Healthy People has represented the United
1. Access to Health Services
2. Clinical Preventive Services
State’s vision for a healthier future, serving as a roadmap
3. Environmental Quality
for the nation by establishing a broad set of overarching
4. Injury and Violence
health goals and specific actions (communicated by high5. Maternal, Infant, and Child Health
6. Mental Health
priority health issues, Figure 2) to improve length and
7. Nutrition, Physical Activity, and
quality of life. The Healthy People initiative is grounded in
Obesity
8. Oral Health
the principle that setting national objectives and
9. Reproductive and Sexual Health
monitoring progress can motivate action, and indeed, in
10. Social Determinants
just the last decade, preliminary analyses indicate that the
11. Substance Abuse
12. Tobacco
country has either progressed toward or met 71 percent of
its Healthy People targets. On December 10, 2010, the U.S.
Adapted from HealthyPeople.gov
Department of Health and Human Services unveiled Healthy People 2020. www.healthypeople.gov/2020
Vision A society in which all people live long, healthy lives.
Mission Healthy People 2020 strives to:





Identify nationwide health improvement priorities.
Increase public awareness and understanding of the determinants of health, disease, and
disability and the opportunities for progress.
Provide measurable objectives and goals that are applicable at the national, State, and local
levels.
Engage multiple sectors to take actions to strengthen policies and improve practices that are
driven by the best available evidence and knowledge.
Identify critical research, evaluation, and data collection needs.
Overarching Goals




Attain high-quality, longer lives free of preventable disease, disability, injury, and premature
death.
Achieve health equity, eliminate disparities, and improve the health of all groups.
Create social and physical environments that promote good health for all.
Promote quality of life, healthy development, and healthy behaviors across all life stages.
Figure 3
PoC
Healthy
Improved People
2020
Patient
Knowledge care
to Practice
(EBM)
The Preceptor Vol 1; No 5
The goal of this newsletter is to highlight the use of a
self-directed, online learning CME activity (Internet
Poc) and its’ potential role in translating new
knowledge into practice, improving patient care and
health outcomes, and achieving Healthy People 2020
goals (Figure 3).
4
Checklist for Implementing Internet PoC in your Practice
This CME activity encourages physician life-long learning, self-direction, selfassessment, reflection and evidence use; active learning interventions with the
potential to change practice behaviors and improve health care outcomes.

An Internet PoC CME activity will be released fall 2014 with details and portal link
emailed to LMU-DCOM appointed Clinical Adjunct Faculty.

Register for/log in to the Internet PoC activity, read the PoC instructions, and
complete the required webform fields.

Idenitify a topic relevant to your patient population/health care practice which
addresses a need in health care (e.g., pain management, hypertension screening,
domestic violence screening).

Record your clinical question and description of search process (we recommend
the PICO(T) model: Patient or Population, Intervention, Control, Outcome, and Time
on page 6 of the newsletter). Ex. of clinical question: How effective is yoga for
treating back pain in the elderly?

Search for the answer to your clinical question through the Dr. Lon and Elizabeth
Parr Reed Health Sciences (LMU-DCOM) Library EBM resources on
http://library.lmunet.edu/medlib (see page 7 of the newsletter). You will need
your user name and password provided to you at the time of clinical adjunct
faculty appointment.

Document the EBM resources you used to answer your clinical question, in the
online form. Include citations (author, title, date, etc) or copy and paste the url
address. Examine author bias, acknowledgements, and institutional affiliations in
order to assess source validity.

Provide a brief summary of the answer to your clinical question including how
you will apply the findings to your clinical practice /patient care.

Identify if the Internet PoC activity resulted in a change in Competence (e.g.,
demonstrating the ability to apply knowledge), Performance (e.g., implementing
learned strategies in practice), and/or Patient Outcomes (e.g., the end results of
particular health practices and interventions).
 Complete the brief PoC activity evaluation and ownload your CME certificate for .50
AOA Category 2-B credit (pending) or AMA .50 PRA Category 1 Credit™. 0.5 CME
credits may be earned for each qualifying search performed, to a maximum of 20
credits per year.
The University of New England College of Osteopathic Medicine (UNECOM) is accredited by the American
Osteopathic Association (AOA) and the Maine Medical Association’s Committee on Continuing Medical
Education and Accreditation to provide continuing medical education for physicians. UNECOM designates this
online CME activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)TM.
The Preceptor Vol 1; No 5
5
Meet Your LMU-DCOM Medical Librarians
Librarians may assist LMU-DCOM clinical adjunct faculty members with literature search
instruction and database advice. Both librarians, Emily Weyant and David Petersen, are
located at the Harrogate, TN campus of Lincoln Memorial University and are available for
consultation via phone and e-mail. For specific contact information and office hours for
medical and health science librarians, please see the contact page of the Dr. Lon and Elizabeth
Par Reed Health Sciences Library website at: http://library.lmunet.edu/medlib_contact . See
below for more information on individual librarians.
Emily Weyant currently serves as the medical librarian at Lincoln Memorial University (LMU).
She is a liaison to the medical school program at LMU. Ms. Weyant graduated with her
master’s degree in library and information science from Syracuse University. Prior to arriving
at LMU, she spent two years working as a library fellow at the Centers for Disease Control and
Prevention in Atlanta, Georgia. Ms. Weyant is a member of the Academy of Health Information
Professionals through the Medical Library Association. Her research interests include
preventive medicine, point-of-care tools, and information literacy, access, and education.
David Petersen is the Health Sciences Librarian at Lincoln Memorial University (LMU). He is a
liaison to the physician assistant and nursing programs. Mr. Petersen graduated from Florida
State University and previously worked at Miami (FL) Children’s Hospital’s Medical Library
for five years. He is a member of the Academy of Health Information Professionals (AHIP)
through the Medical Library Association. His research interests center on the use of mobile
technologies in healthcare, open access, and education.
Tips for Searching the Literature
In order to search literature effectively according to EBM standards, you may wish to
formulate your question according to PICO(T) format. PICO(T) is an acronym that stands for
population, intervention, control, outcome, and time. Unlike the other elements of PICO(T),
time is not consistently used, which is why it is enclosed in parenthesis. For more complex
examples, visit the University of Oxford’s Medical Literature Searching Skills page at:
http://learntech.physiol.ox.ac.uk/ cochrane_tutorial/cochlibd0e187.php
The question
you need to
answer.
ex: How
effective is yoga
for treating back
pain in the
elderly?
Population
Intervention
Control
Outcome
Time
ex: The elderly.
ex: Yoga.
ex: No yoga.
ex: Reduction in
back pain or not.
ex: One year.
The Preceptor Vol 1; No 5
6
Library Resources
Relevant resources provided to appointed clinical adjunct faculty through the Reed Health
Sciences Library.
EBM
Resources
Description
PoC
Resources
Cochrane
Library
Includes Cochrane systematic
reviews, other systematic review
abstracts, and more.
UpToDate
Annual Reviews
Synthesizes the vast amount of
primary research literature and
identifies the principal
contributions in your field.
Systematically searches a wide
range of international medical
journals applying strict criteria for
the validity of research.
VisualDx
Evidence Based
Medicine (BMJ)
Description
Includes original, peer-reviewed
entries for 20 medical specialties to
allow practitioners to keep current
with new clinical developments and
more.
Includes an interactive tool for
finding differential diagnoses based
on visual findings.
Resource Spotlight
Recommended free EBM and PoC resources.
Free EBM Resources
NICE
National Institute for
Health and Care Excellence
BestBets
TRIP Database
Turning Research Into
Practice
MedScape Reference –
Diseases and Conditions
National Guideline
Clearinghouse
PubMed, Clinical Queries
Center for EBM
Description
Summaries of current
evidence bases and best
practices
Provides EBM answers to
specific clinical problems
Provides special
interfaces for performing
a PICO search (without
time) or rapid review
EBM information by
specialty
EBM clinical practice
guidelines
Clinical search tools
EBM tools and resources
Free PoC Resources
Epocrates
Apple Android
MedScape
Apple Android
Canopy
Apple
MediBabble
Apple
QxMd
Apple Android
Description
Drugs, diseases,
interactions, and
tables
Patient education,
news, pharm info, etc.
Medical translator sign up for a free
access code
Medical translator
Clinical calculator and
decision support tool
Additional Assistance
For additional assistance with library resources please contact Emily Weyant or David Petersen at
Emily.Weyant@lmunet.edu and David.Petersen@lmunet.edu, respectively. You may access the
library webpage at http://library.lmunet.edu/medlib.
The Preceptor Vol 1; No 5
7
Key Points

Internet Point of Care (PoC) can be a useful tool in highlighting clinical
questions, which are consistent with Healthy People 2020 initiatives.

Internet PoC CME activities can facilitate active learning, reflection, selfassessment, and life-long learning habits of clinicians.

Internet PoC CME offers structured, self-directed, online learning for physicians
on topics relevant to their clinical practice

Medical librarians and Health Information Technology (HIT) is an essential part
of PoC CME planning and learning, providing a valuable resource for clinical care
decisions.

Implementing PoC CME activities in your practice can impact patient care and
public health and, benefit the nation’s HealthyPeople2020 initiatives.

Evidence Based Medicine (EBM) relates to PoC in that it requires physicians to
take an active role in finding and assessing evidence within literature.

Medical and Health Science Librarians may assist physicians in performing
literature searches where available.

Physicians may form questions according to PICO(T) format in order to ensure
that they are have a clear idea of what kinds of evidence they are looking for
within the literature.

The Reed Health Sciences Library at Lincoln Memorial University provides
appointed clincial adjunct faculty with access to EBM and PoC resources
including UpToDate and Cochrane Library.

Many EBM and and PoC resources are available for free via the internet or as
mobile apps that are designed for physician use in clinical care settings.
The Preceptor Vol 1; No 5
8
Suggested Reading and Resources
Point of Care (PoC)
Accreditation Council for Continuing Medical Education (ACCME)
http://www.accme.org/ask-accme/how-does-accme-define-internet-searching-andlearning-activity
Bjerre LM, Paterson NR, McGowan J, et al. What do primary care practitioners want to
know? A content analysis of questions asked at the point of care. J Contin Educ Health
Prof. Fall;33(4):224-234.
Demner-Fushman D, Hauser SE, Humphrey SM, Ford GM, Jacobs JL, Thoma GR.
MEDLINE as a source of just-in-time answers to clinical questions. AMIA Annu Symp
Proc. 2006:190-194.
Hauser SE, Demner-Fushman D, Jacobs JL, Humphrey SM, Ford G, Thoma GR. Using
wireless handheld computers to seek information at the point of care: an evaluation by
clinicians. J Am Med Inform Assoc. Nov-Dec 2007;14(6):807-815.
Mangrulkar RS. Targeting and structuring information resource use: a path toward informed
clinical decisions. J Contin Educ Health Prof. Fall 2004;24 Suppl 1:S13-21.
Evidence-Based Medicine
1. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine:
what it is and what it isn't. BMJ. Jan 13 1996;312(7023):71-72.
2. Vrdoljak D. Teaching evidence based medicine in family medicine. Acta Med Acad. Jan 15,
2013;41(1):88-92.
3. O'Sullivan D, Wilk S, Michalowski W, Farion K. Using PICO to align medical evidence with
MDs decision making models. Stud Health Technol Inform. Aug 8, 2013;192:1057.
4. Belsey J. What is Evidence-Based Medicine? What Is
5.
6.
7.
8.
9.
Series. http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/ebm.pdf. Pub
lished May 2009. Accessed July 31, 2014.
Spence D. Evidence based medicine is broken. BMJ. 2014-01-03 11:26:13;348.
Light DW. Risky Drugs: Why The FDA Cannot Be Trusted. Harvard University Edmond J.
Safra Center for Ethics. http://www.ethics.harvard.edu/lab/blog/312-risky-drugs.
Accessed June 4, 2014.
Sismondo S, Doucet M. Publication ethics and the ghost management of medical
publication. Bioethics. Jul 24 2009;(6):273-283.
Upshur RE, Tracy CS. Rebuttal: Is evidence-based medicine overrated in family medicine?:
Yes. Can Fam Physician. Nov 2013;59(11):e475.
Every-Palmer S, Howick J. How evidence-based medicine is failing due to biased trials and
selective publication. J Eval Clin Pract. May 4, 2014; doi: 10.1111
The Preceptor Vol 1; No 5
9
Healthy People 2020
Basu S, Seligman H, Winkleby M. A metabolic-epidemiological microsimulation model to
estimate the changes in energy intake and physical activity necessary to meet the
healthy people 2020 obesity objective. Am J Public Health. Jul 2014;104(7):1209-1216.
Continuing Education Programs:
www.healthypeople.gov/2020/learn/ContinueEducation.aspx
Healthy People 2020 Framework:
www.healthypeople.gov/2020/Consortium/HP2020Framework.pdf
Hudmon KS, Addleton RL, Vitale FM, Christiansen BA, Mejicano GC. Advancing public health
through continuing education of health care professionals. J Contin Educ Health Prof.
Fall;31 Suppl 1:S60-66
Koh HK, Nowinski JM, Piotrowski JJ. A 2020 vision for educating the next generation of public
health leaders. Am J Prev Med. Feb 2011;40(2):199-20
Press Release: www.healthypeople.gov/2020/about/DefaultPressRelease.pdf.
The Preceptor Vol 1; No 5
10