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Point of Care Decision Support Resources [online and iPhone] Nancy Clark, M.Ed. Director Medical Informatics Education FLORIDA STATE UNIVERSITY The College of Medicine 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 FLORIDA STATE UNIVERSITY Session 4 The College2 of Medicine 2 Handouts • • • • • PowerPoint Decision Support Handout Evaluation Using Resources with Students Find it Quickly for iPhone/iPad FLORIDA STATE UNIVERSITY Session 4 The College3 of Medicine 3 PDA Versions Available Pocket PC Product iPhone Blackberry Android x x x x x x x x Rx Essential Evidence+ x x Access Online Access Online Harrison's Practice x x x x x PEPID x x x x x Geriatrics At Your Fingertips x x $$ x Pediatric Care Online x x x FLORIDA STATE UNIVERSITY x x x The College of Medicine x x x x Palm (Windows Mobile) DynaMed x Epocrates Essentials Clinical Evidence Access Online 4 Current Library Web Site (Sum 2010) FLORIDA STATE UNIVERSITY Summer 2010 The College of Medicine 5 New Library Webpage (Fall 2010) FLORIDA STATE UNIVERSITY Summer 2010 The College of Medicine 6 Resource Content Resource Rx DDx DxPlain Online Dx LAB Calcs X Epocrates Essentials PDA X Epocrates Online X PEPID Online and PDA X Dynamed Online and PDA X X Harrison's Practice Online and PDA X X X* Essential Evidence Plus Online and PDA FLORIDA STATE UNIVERSITY X Pediatric Care Online Online The College of Medicine X X X X X X X X X X online X X X X Use of DDx Tools with Students • During presentation of Patient with acute problem • Ask student for DDx • Tell student to use DxPlain, Epocrates Sx, which they have, or PEPID and name other possibilities FLORIDA STATE UNIVERSITY Session 4 The College8 of Medicine 8 P P P P P Disease Reference Lab Reference Calculators Differential Diagnosis Drug Information PEPID FLORIDA STATE UNIVERSITY The College of Medicine PEPID CRC • Web and PDA (iPhone, Android, and Blackberry) • Disease reference, drugs, interactions, lab manual, clinical clerkships, calculators, images. • 2,700 Disease and Trauma topics with diagnosis, pathophysiology, treatment and disposition • Includes Stedman’s Medical Dictionary FLORIDA STATE UNIVERSITY The College of Medicine 10 PEPID DDX • Enter symptoms, exam, labs • DDx nicely numbered as to likelihood • Linked to disease info for more information FLORIDA STATE UNIVERSITY Seminar 4Session 4 The College11 of Medicine PEPID Content • Diseases info broken down into Diagnosis and Treatment FLORIDA STATE UNIVERSITY The College of Medicine 12 PEPID on the PDA • 100% of content on web • Links between diseases, drugs, images and calculators. FLORIDA STATE UNIVERSITY The College of Medicine 13 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? FLORIDA STATE UNIVERSITY The College of Medicine PEPID Calculators • Both medical equations and “Scores” • Online and PDA same instruments FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 15 PEPID Calculators PDA • Under Table of Contents or • Icon on tool bar • Alphabetical List or by category • Icon in text FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 16 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? • Calculate your own ATPIII 10 year risk for heart disease based on your age, gender, cholesterol and smoking status. • Optional: Find your CAGE score. F S U LORIDA TATE NIVERSITY Session 5 The College of Medicine 17 • PEPID Lab Manual Online/PDA Contents: – Clinical rotations (Peds, Surg, IM, etc.) – Calculators – Disease reference – Drug information and interaction tool – Lab Manual – Stedman’s Dictionary – Illustrations (anatomy, EKG strips, etc.) – Procedures FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 18 PEPID Lab Manual FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 19 Disease Reference Lab Reference Calculators P Differential Diagnosis Drug Information DXPLAIN FLORIDA STATE UNIVERSITY The College of Medicine 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 FLORIDA STATE UNIVERSITY Session 4 The College21 of Medicine 21 DxPlain • Very powerful expert system • Included in ePocrates Essentials (Sx) on Windows Mobile and Palm only • From Harvard • Age, gender and duration • Allows for multiple symptoms and lab results • Get Dx information FLORIDA STATE UNIVERSITY Session 4 The College22 of Medicine 22 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. FLORIDA • What could this be?STATE UNIVERSITY The College of Medicine P P P Disease Reference Lab Reference* Calculators Differential Diagnosis P Drug Information *PDA Only EPOCRATES FLORIDA STATE UNIVERSITY The College of Medicine Epocrates Online and PDA • Disease Tab (3/1/10) • Content from BMJ • Same content in iPhone Epocrates Essentials • Nice images • Nice highlights summary first screen • Organization: – – – – – – Summary Basics Diagnosis Treatment Follow-Up References FLORIDA STATE UNIVERSITY The College of Medicine Epocrates Dx • New content from BMJ • Linked drugs to Rx • Linked from Lab to Dx • Excellent Interface • Images • Sections List – – – – – – – Basics Differential Hx/Exam Tests Tx Options Follow-up Image Library FLORIDA STATE UNIVERSITY Session 4 The College of Medicine 26 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? FLORIDA STATE UNIVERSITY The College of Medicine MedCalc on Epocrates Online • Online version is better than PDA version • MedCalc3000 $29.95/yr (medcalc3000.com) • Extensive medical calculators and clinical rules, decision trees • Organized by specialty or alphabetical FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 28 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 FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 29 Epocrates Online Clinical Criteria FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 30 MedCalc3000 Calculators • Also available online in – Dynamed – Facts and Comparisons FLORIDA STATE UNIVERSITY The College of Medicine 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? FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 32 MedMath in Epocrates PDA • • • • Few basic calculators Under X2 Tools MedMath Pick calculator FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 33 Exercises for Practice • Calculate your own Body Mass Index, Ideal Body Weight, Basal Energy Expenditure, and Body Surface Area. • 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? FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 34 Epocrates Essentials Lab on PDA • Labs only • Interpretation linked to Rx and Dx sections • Panels • Browse or search FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 35 Exercises for Practice • A basic metabolic panel reveals that a 30 year old man suffering from bipolar disorder has a serum calcium level of 10.9 mg/dL. He is taking lithium and valproate. Could his medications be a factor? FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 36 P Disease Reference Lab Reference Calculators Differential Diagnosis P Drug Information HARRISON’S PRACTICE FLORIDA STATE UNIVERSITY The College of Medicine Harrison’s Practice • • • • Address disease quick reference needs Nice interface From Access Medicine/Harrison's Web and PDA versions – contains LexiDrug database • Content Internal Medicine focus • Easy to navigate – content growing FLORIDA STATE UNIVERSITY The College38 of Medicine Harrison’s Practice PDA • • • • • • BASICS: Definition, Epidemiology, Risk Factors, Etiology, Associated Conditions DIAGNOSIS: Symptoms & Signs, Differential Diagnosis, Diagnostic Approach, Laboratory Tests, Imaging, Diagnostic Procedures, Classification TREATMENT: Treatment Approach, Specific Treatments, ONGOING CARE: Monitoring, Complications, Prognosis, Prevention RESOURCES: ICD-9-CM, See Also Internet Sites, References PEARLS FLORIDA STATE UNIVERSITY Session 4 The College of Medicine 39 Exercises for Practice • In acute respiratory distress syndrome, during the exudative phase, what findings appear on a chest x-ray? • • What is the mortality rate for Rocky Mountain Spotted Fever? FLORIDA STATE UNIVERSITY The College of Medicine P Disease Reference Lab Reference P Calculators Differential Diagnosis Drug Information DYNAMED FLORIDA STATE UNIVERSITY The College of Medicine DynaMed • Combines summary of topics with latest evidence on topic • Updated constantly (more up to date than UpToDate) • Links out to articles and reviews if more details needed – run PubMed first, minimize PDA FLORIDA STATE UNIVERSITY Session 4 The College42 of Medicine and Online 42 DynaMed Organization of Results • Description (including ICD9 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 • 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 • Physical Reviews and Guidelines) – Skin, HEENT, Neck, • Patient Information Extremities, Neuro, Pelvic FLORIDA STATE UNIVERSITY Session 4 The College of Medicine 43 DynaMed PDA • • • • • • Complete disease content of web site Free to faculty and students Navigation can be tricky Lots of scrolling Linking out only works if wireless iPhone, Blackberry, Android, Palm and WM versions FLORIDA STATE UNIVERSITY Session 4 The College44 of Medicine 44 Calculators in Dynamed • Online Medcalc 3000 (same as Epocrates Online) • On the PDA, Archimedes free with Skyscape FLORIDA STATE UNIVERSITY The College of Medicine 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? • What is the prognosis for a 60 y/o female with Stage IV metastatic breast cancer? FLORIDA STATE UNIVERSITY The College of Medicine P Disease Reference* Lab Reference P P Calculators Differential Diagnosis Drug Information *evidence summaries by disease ESSENTIAL EVIDENCE PLUS FLORIDA STATE UNIVERSITY The College of Medicine 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) FLORIDA STATE UNIVERSITY The College of Medicine EE+ iPhone/iPod • Access EE+ online in PDA formatted webpage. Use Safari. www.eeplus.mobi/m FLORIDA STATE UNIVERSITY The College of Medicine Essentials Evidence + • Web page See Handout for list of calculators FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 50 Derm Expert • • • • Dermatological DDx Web and PDA Pick your lump or bump Drill down to the disease with images FLORIDA STATE UNIVERSITY The College of Medicine Essential Evidence Plus (EE+) Calculators (formerly InfoRetriever) • 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 FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 52 EE+ Online and PDA • Three Types of calculators – Decision Support Calculators (index) – Diagnostic Test Calculators – History and Physical Test Calculators FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 53 Clinical Rules and Calculators • Link bottom right of Web site • On PDA, First thing under Tools See Handout for list of calculators FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 54 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 FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 55 EE+ Decision Support Calculators • • • • • Some medical equations Estimate the likelihood of a diagnosis Calculate risk for disease Estimate a prognosis Determine actions FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 56 Exercises for Practice • A 45 year old man has been a smoker for over 20 years is worried that he might have diabetes mellitus because his father had it. He does not think anyone else in his family has ever been diagnosed with it. He is 6 feet tall and weighs 250 pounds. What is his Diabetes risk score? You will first need to determine his body mass index. FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 57 EE+’s Coding Tool • Just ICD-9 disease and V codes, no E codes • On PDA, under Tools • Online, Link at bottom right of web site • Enter term • Search FLORIDA STATE UNIVERSITY Session 5 The College of Medicine 58 P Disease Reference Lab Reference P Calculators* Differential Diagnosis P Drug Information *Online Only PEDIATRIC CARE ONLINE FLORIDA STATE UNIVERSITY The College of Medicine Pediatric Care On-line FLORIDA STATE UNIVERSITY The College of Medicine In Summary Resource Epocrates Essentials PDA DDx Dx LAB Calcs X* X Epocrates Online X X PEPID Online and PDA X X X X X X X Dynamed Online and PDA X Harrison's Practice Online and PDA X Essential Evidence Plus Online and PDA X X Pediatric Care Online Online FLORIDA STATE UNIVERSITY X The College of Medicine X X Next Session • Drug References – Meredith Goodwin – 3:00-5:00 pm, Wednesday, Aug 4. FLORIDA STATE UNIVERSITY The College of Medicine