THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Point of Care
Decision Support Resources
[online and mobile]
, MD, Regional Campus Informatics Director
Nancy Clark, M.Ed., Director of Medical Informatics Education
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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
Session 4
2
2
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Handouts
•
•
•
•
•
PowerPoint
Decision Support Handout
Evaluation
Using Resources with Students
List of Free or Cheap Medical Apps
Session 4
3
3
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
New Library Webpage
(Fall 2010)
• Prototype at
• http://dev.cimes.fsu.edu/fsucom/prototype/
Summer 2010
4
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
POC Decision Support Tools
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
EZProxy Reminder
• Off campus: Log into EZProxy with CoM username
and password
• Use library page links to access online resources
firstname.lastname
$fsumed$xxxx
7/11/2016
Intro to Medical Library Resources
6
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Mobile Device Versions Available
•
•
•
•
Dynamed
Epocrates Essentials
Essential Evidence Plus
Natural Medicines
Database
• Pediatric Care Online
• PEPID
• Medical Letter
• uCentral:
–
–
–
–
–
–
5 Minute Clinical Consult
Clinical Evidence
Diagnosaurus
Harriet Lane
Harrison’s Manual
Johns Hopkins ABX,
Diabetes and HIV Guides
– Washington Manual
7
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Resource
DxPlain Online
Rx
DDx
Resource Content
X
Dx LAB Calcs
Epocrates Essentials PDA
X
X
Epocrates Online
X
X
PEPID Online and PDA
X
Dynamed Online and PDA
X
Essential Evidence Plus Online and PDA
Pediatric Care Online Online
X
X
X
Diagnosaurus Online and PDA
X
uCentral Online and PDA
X
X
X
X
X
X
X
X
X
X
X
X
X
X
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
P
P
P
P
P
PEPID
Disease Reference
Lab Reference
Calculators
Differential Diagnosis
Drug Information
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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
11
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
PEPID Mobile
• 100% of content on web
• Links between diseases,
drugs, images and
calculators.
12
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
PEPID CRC Disease
• Web and PDA (iPhone, iPad, Android, and Blackberry)
• 2,700 Disease and Trauma topics with
diagnosis, pathophysiology, treatment and
disposition
13
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
PEPID Disease Content
• Diseases info broken down into
Diagnosis
and
Treatment
14
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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?
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
PEPID Calculators
• Both medical equations and “Scores”
• Online and PDA same instruments
Session 5
16
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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
17
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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
18
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
PEPID Lab Manual
Session 5
19
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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
20
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
PEPID DDX
• Enter symptoms, exam, labs
• DDx nicely numbered as to likelihood
• Linked to disease info for more information
Seminar 4Session 4
21
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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).
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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
Session 4
23
23
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Disease Reference
Lab Reference
Calculators
P
Differential Diagnosis
Drug Information
DXPLAIN
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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
Session 4
25
25
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
DxPlain
•
•
•
•
•
Very powerful expert system
From Harvard
Age, gender and duration
Allows for multiple symptoms and lab results
Get Dx information
Session 4
26
26
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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?
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
P
P
P
Disease Reference
Lab Reference*
Calculators
Differential Diagnosis
P
Drug Information
EPOCRATES
New iPad version released 11/12/12
*PDA Only
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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
Session 4
29
29
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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?
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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
31
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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
32
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Epocrates Online Clinical Criteria
Session 5
33
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
MedCalc3000 Calculators
• Also available online in
– Dynamed
– Facts and Comparisons
– Medscape
– MerckMedicus
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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
35
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
MedMath in Epocrates PDA
• Does not have same
calculators as Epocrates
Online.
• Few basic calculators
• Pick Calculator or type in
Search box.
Session 5
36
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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
37
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Epocrates Essentials
Lab on PDA
• Labs only
• Interpretation linked to Rx
and Dx sections
• Search or
• Browse Panels or
Specimen type
Session 5
38
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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
39
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
P
Disease Reference
Lab Reference
P
Calculators
Differential Diagnosis
P
DYNAMED
Drug Information
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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
Session 4
41
41
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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.
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
DynaMed Organization of Results
• Description (including ICD-9
Codes)
• Diagnosis
– Making the diagnosis, Rule
out, Tests to order, Blood tests,
Urine studies, Imaging studies,
Pathology tests, Other
diagnostic testing
– Description, Also called, ICD-9
Codes, Types, Organs Involved,
Who Is Most Affected,
Incidence/Prevalence
• Prognosis
• Treatment
• Causes and Risk Factors
– Causes, Pathogenesis, Likely
risk factors, Possible risk factors
– Treatment Overview, Diet,
Activity, Counseling,
Medications, Surgery,
Consultation and referral,
Other management, Follow-up
• Complications and Associated
Conditions
• History
– CC, HPI, Meds, PMH, FH, SH,
ROS
• Prevention and Screening
• References (including Reviews
and Guidelines)
• Patient Information
• Physical
– Skin, HEENT, Neck, Extremities,
Neuro, Pelvic
Session 4
43
43
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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
Session 4
44
44
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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?
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Calculators in Dynamed
• Online Medcalc 3000 (same as Epocrates
Online)
• On the PDA, Archimedes free with Skyscape
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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.
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
P
Disease Reference
Lab Reference
Calculators
P Differential Diagnosis
uCentral:
Drug Information
P
Diagnosaurus,
5 Minute Clinical Consult, etc.
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
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
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Diagnosaurus
• DDX tool
• Look up a symptom or
presenting problem
• Get a list of possible
diagnoses
• Linked to content in
5MCC
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
5 Minute Clinical Consult
• Ideal disease quick
reference
• Bulleted lists
• Updated annually
• Navigation on left
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
P
Disease Reference*
Lab Reference
P
P
Calculators
Differential Diagnosis
Drug Information
*evidence summaries by disease
ESSENTIAL EVIDENCE PLUS
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Essential Evidence Plus
• Evidence based resource for:
– Cochrane Abstracts
– InfoPOEMS
– Summaries of latest evidence on
conditions/diseases
– Clinical decision/prediction tools
– Guidelines
– Calculators
– Dermatologic DDx (Derm Expert)
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
EE+ iPhone/iPod
• Access EE+ online in PDA formatted webpage.
Use Safari. www.eeplus.mobi/m
• Requires either a wireless or cell connection
to use.
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Essentials Evidence +
• Web page
See Handout for list of calculators
Session 5
55
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Derm Expert
•
•
•
•
Dermatological DDx
Web and PDA
Pick your lump or bump
Drill down to the disease with images
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Essential Evidence Plus (EE+) Calculators
• Few medical equation calculators, many
decision rules
• Evidence based, translating guidelines into
decision tools
• Appear in content of keyword search
• Separate index of just Decision Support clinical
rules and calculators
Session 5
57
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
EE+ Online and PDA
• Three Types of calculators
– Decision Support Calculators (index)
– Diagnostic Test Calculators
– History and Physical Test Calculators
– Tutorials on how to use under Support online
Session 5
58
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Clinical Rules and Calculators
• Link bottom right of
Web site
• On PDA, First thing
under Tools
See Handout for list of calculators
Session 5
59
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Using EE+ Rules & Calculators
• Several ways to locate
calculators
1. Look up a disease and
expand section needed
(Dx, Tx, etc.) and refine
by type of resource
2. Browse by Resource
and select Clinical Rules
and Calculators, then
drill down to disease
Session 5
60
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
EE+ Decision Support Tools
•
•
•
•
•
Some medical equations
Estimate the likelihood of a diagnosis
Calculate risk for disease
Estimate a prognosis
Determine actions
Session 5
61
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Exercises for Practice
• In the ER a 19 y.o. MVA patient is
semiconscious. He opens eyes to pain only,
metters nonsensical sounds intermittently,
and localizes extremity movements to painful
stimuli. What is his Glascow Coma Scale
score?
Session 5
62
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Exercises for Practice
• According to the EE+ Screening: cardiac risk
profile (Framingham data) tool, what is the
Framingham 10 year risk of Miocardial
Infarction (MI) for a 64 yr old man with the
following cardiac risk factors:
• BP 126/86, Total Chol 188, LDL 111, HDL 42,
Smoking? Yes, Diabetic? Yes
Session 5
63
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
P
Disease Reference
Lab Reference
P
Calculators*
Differential Diagnosis
P
Drug Information
PEDIATRIC CARE ONLINE
*Online Only
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Pediatric Care On-line
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Using Mobile Resources with Patients
• Patients think you are texting or taking photos
• Reassure patient you are not
• Tell the patient what you are doing (looking up
patient’s medications, interactions…)
• Share information found
• Maintain eye contact with patient as much as
possible
Message given to students on using technology with patients.
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
Some Free Decision Support Apps
• App Directory in
Epocrates – adding new
tools
• Medscape
• Calculate by QxMD
• See Handout on
Free/Cheap Med Apps
THE FLORIDA STATE UNIVERSITY COLLEGE OF MEDICINE
Educating and developing exemplary physicians who practice patient-centered health care
In Summary
• Great resources for decision support are
available to you
• Help teach students to use them by modelling
their use
• Involve student in decision making process
• Always adding new resources