EBM for the busy Clinician‘Putting your Smart Phone to Work’

Gil C. Grimes, MD

Bias Identification Slide

• I have reviewed sections in DynaMed in the past

• I do not have any commercial affiliations outside Health PEI

• I am from Texas and at times may feel better about myself than required by law.

• I like technology.

Why Bother?

Objectives

• Levels of Evidence• DOE vs. POEMs• Sources for Evidence• Tools for the Bedside• Non-medical Handheld Tools

First a few Questions

• I am familiar with Evidence Based Medicine?• Databases and sites that I routinely use to obtain

information?

What is EBM?

• Simply put it is the integration of research evidence with clinical expertise and patient values.

• EBM will allow us to do more good than harm• Patients want to know the following

o “Will it make me live better”o “Will it make me live longer”

Levels of Evidence

• This is a method for grading journal articles, guidelines etc.

• This is not “universal” • AAFP uses Level A, B, C • Centre for EBM Oxford uses 1,2,3

o Focuses on the type of article and qualityo Therapy/Prevention/Etiology/Harm,

Diagnosis, Prognosis• Either way is just fine

Where’s the beef?

• Levels of evidence are good….

• What I want to know is how this will work for me.

• Friends the path requires moving from DOE to POE…

Disease Oriented Evidence• Most common type of

evidence found in research journals

• Important to our understanding of disease

• Responsible for many therapeutic advances

• Intended for a research audience

• Pathophysiology • Pharmacology • Etiology

Patient Oriented Evidence

• Uncommon in most journals

• Outcomes patients care about

• Mortality • Morbidity • Quality of Life• Cost• Harm

POEMs

• Patient-Oriented Evidence that Matterso Addresses a clinical

problem encountered by primary care physicians

o Uses patient-oriented outcomes

o Potential to change our practice if valid and applicable

DOES vs. POEMs

• The Numbers….o 6 month survey of 90 journalso 8,047 articleso 213 POEMs

• 97% DOEs and other material

• 2.6% POEMsJ Fam Pract 1994;38:505-13.

So where do I find this?

• You could search the literatureo Yeah like you have that much time!

• You could ask you colleagueso Expert opinion Level C

• You could familiarize yourself with one or two good sourceso That sounds pretty good…

Usefulness equation

• Usefulness= relevance x validitywork

• Go for sources that have done the work for you

Systematic Reviews

Summarized Evidence-Referenced Resources

Research Articles

Other Sources

Search Strategies

• Database Sizeo Larger the database, tighten the searcho Small database, broaden the search

• Languageo A little time on a tutorial can save you hours

over a montho Especially PubMed

DynaMed• Created by Brian Alper, MD• Evolved from his ‘black book of facts’• Background information

o Better for review than Up-to-dateo Discusses diagnosis, treatment, etc.

• Evidence based• Peer reviewed• Can be used to generate scholarly activity in

residency• I use this resource multiple times daily

DynaMed

• Supported Deviceso Palmso Pocket PCo Windows Smartphone o BlackBerryo iPhone and iPod Touch Android

Smartphones• Web Based availability

Essential Evidence Plus

• Founded by three Family Physicians, a PharmD and a Psychologist

• Goal to improve the health and lives of people by providing patient-oriented evidence that matters in a rapid and accessible form

• Very good on computers, OK on handhelds

Essential Evidence Plus

• Essential Evidence are good quick summaries (slightly shorter than Dynamed) o Nice bottom line approach to diseaseo Not as frequently updatedo Little clunky on the BlackBerry

• Calculator Section very useful o Mortality, warfarin, pre-op eval etc.

• Let’s Look

Web Based Stuff

• Trip Database- an aggregator service for medical data that sorts by Level of Evidenceo Excellent resource for patient handoutso Free

• PubMed- great site for research, no really, you just have to know how to use it.

Relevance

• Slice the bedside stacko Is this something that is common to my

practice?o Is it an outcome my patients would care

about?o If the outcome is true would I have to

change my practice?• If relevant then examine for validity

Pushed or Pulled

• Keeping up in medicine is tough• Pushed information helps

o InfoPOEMSo Journal Contents

• Pulled Informationo Learning as you need too Just in time information

Handhelds

• This is the key to just in time information

• InfoRetriever and DynaMed can run off Palm or Microsoft handheld

• Very functional• Gives you decision tools in your hand

when you need them

Programs worth Having

• Epocrates• iSilo• LyteMeister• ICD Meister• CPT Meister

• Geriatrics at your Fingertips

• Family Practice Management has a good articleo July/August 2006

Demonstrations of Handheld

Non-medical Programs

• Google Bookmarkso www.google.com/profiles/doctorgilgrimes?hl=en

• Evernoteo www.evernote.como A means to an end for keeping everything in the

cloud• reQall

o www.reqall.como Reminding yourself of things you forgot

Questions?