American College of Physicians: Internal Medicine — Doctors for Adults ®

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Need a quick consult? Try this new College product

From the March ACP-ASIM Observer, copyright 2002 by the American College of Physicians-American Society of Internal Medicine.

By Jason van Steenburgh

At Annual Session next month, the College will unveil a new tool designed to give internists fast access to clinical information where they need it most: the point of care.

The Physicians' Information and Education Resource, better known as PIER, will answer internists' questions about treatment protocols, drug dosages and diagnosis. PIER, which will be available on the Web to College members, will provide evidence-based recommendations to help guide internists through perplexing clinical problems.

While there are other Web-based decision-support tools for physicians, PIER's structure sets it apart. Most Web products force you to type in a keyword, then sort through dozens of journal articles or references on a topic. PIER does most of that legwork for you.

PIER's authors have combed through the medical literature and developed synopses that give physicians a broad overview of diseases and conditions that they commonly see. They have then distilled this information into a series of bulleted lists designed to provide guidance.

PIER

PIER's authors have distilled the best evidence-based information the physicians can quickly search at the point of care.

How to find answers

When you go to the PIER Web site, you'll find six different topics to choose from: diseases, screening and prevention, complementary/alternative medicine, ethical and legal issues, procedures and drug resources. Because each topic is further divided into modules, internists can scan PIER and find the exact information they're looking for in seconds, not minutes.

Suppose you have a question about how to best treat essential hypertension. You simply select "disease" on the PIER homepage then select the letter "h." A list of conditions beginning with that letter appears, and you click on essential hypertension. (You can also go to the disease section and type "essential hypertension" or go to PIER's search engine.)

Once you have located the essential hypertension resources, you can select from a list of sub-categories such as prevention, screening and diagnosis. If you click on drug therapies, PIER will offer the following recommendations:

  • Consider a diuretic, -blocker, or an ACE inhibitor for initial treatment of uncomplicated HTN.

  • Consider individualizing antihypertensive therapy for patients with specific comorbid conditions.

  • Consider choosing therapy that may have favorable effects on comorbid conditions, and avoid therapy that may have unfavorable effects.

  • In patients with markedly elevated blood pressure, distinguish between a hypertensive emergency and a pseudocrisis.

To help you judge the quality of these recommendations, PIER ranks the strength of its recommendations based on evidence. Advice supported by at least one high-quality, randomized control trial (RCT) is followed by the letter "A." Information backed by nonrandomized trials, cohort studies, observational studies, case control or any other organized analysis that is not an RCT is ranked "B." Information supported by expert opinion is ranked "C."

If you click on the first word of each recommendation, you'll see more information about who should receive that particular drug. You'll also see links to other information, such as dosages.

When PIER recommends a treatment or gives advice, it offers supporting information to let you judge its merits. Recommendations include a brief sentence explaining the rationale for the advice (years of clinical studies, for example); evidence supporting the recommendation, such as journal articles; and additional pertinent comments.

When you click on the first word of "Consider a diuretic," for example, you'll see links to a page with information about the stages of uncomplicated HTN that are appropriate for the listed drugs. You'll also find a link to a table on drug classes and doses for oral antihypertensive drug treatment.

While PIER presents most information in easy-to-read bulleted lists, it also provides tables, charts, figures, algorithms and even multimedia presentations to help you make decisions.

Because PIER's goal is to offer the latest in medical thinking, it will be updated continuously as new information becomes available. "You can update a disease like rheumatic fever once a year," said David R. Goldmann, FACP, PIER's Editor-in-Chief. "But with conditions that are really hot, like HIV, diabetes or hypertension, things happen on a continual basis and they have to be updated more often."

To help keep internists up to date, Dr. Goldmann added, every disease page will have a "what's new" box with links to the latest research.

Future versions

When the College rolls out PIER next month, internists will see a prototype version with about 100 modules on diseases and a few modules on other topics. Eventually, PIER will have several hundred modules.

The College wants to familiarize internists with PIER as it continues to add new modules and update those already in place. "We are launching a product with a credible body of content that we'd like the membership to try," explained Dr. Goldmann. "We're not saying, 'Here is a brand new Cadillac.' We're saying, 'Here is a concept car we'd like you to try out.'"

Mike Strange, the College's Acting Vice President for Publications, predicted that time-starved internists will find PIER practical. "It's like a pilot's checklist in a 747 vs. a 747 operations manual," he said. While a manual may provide the background for the information in the checklist, Mr. Strange explained, no one would try to fly a plane while reading an entire manual. That's because in a cockpit—just as at the point of care—there isn't enough time to absorb lengthy explanations.

As of April, only College members will have access to PIER. In the future, ACP-ASIM officials said, an annual subscription for PIER will cost about $200.

You may also see PIER's content in other products. One major aim of the project is to integrate its content into electronic medical records (EMR) systems at major medical institutions. The College is presently in negotiations with a major EMR vendor with that goal in mind.

There are also plans to release a handheld version of PIER and to make the tool available as an educational aide.

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