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In one remote area, PIER helps physicians stay current

For two internists with limited subspecialty access, the ACP Web-based tool provides key clinical information

From the December ACP Observer, copyright © 2005 by the American College of Physicians.

By Gina Shaw

In a town in northern Canada, ACP's PIER—the point-of-care, Web-based decision-support tool—is having a big impact on patient care.


Dr. Azzam



Khalid M. Azzam, ACP Member, and Hisham H. Tassi, ACP Member, are the only two internists serving the people of Thompson, Manitoba, and its surrounding area, population 45,000. Winter temperatures in this mining town and transportation hub can hit minus 60, while the nearest academic medical center is 400 miles away.

But at their practice at the 74-bed Thompson General Hospital and the attached Northern Consultation Centre, Drs. Azzam and Tassi rely on PIER's evidence-based disease and procedure modules every day.

"I've been using it from the first day I arrived," said Dr. Azzam, who came to Thompson two years ago from Buffalo, N.Y. "We are considered to be the specialists in the region." Repeatedly called upon by the other members of Thompson's small medical community, Dr. Azzam said he finds PIER's "layered approach" particularly helpful. "You can easily get to the level of information you want—either a quick answer or more in-depth information if you have the time, or even the original article that generated the information."

A clinical lifeline

For the two internists with limited subspecialty access, PIER has become a critical information lifeline.

"Other than us, there is one general surgeon, a psychiatrist, a locum pediatrician and 14 family practitioners," Dr. Azzam explained. "All the family physicians depend on us to handle referrals." Consults with specialists at the nearest academic center—University of Manitoba—are available by telephone, but aren't practical for day-to-day case management.

Before moving to Canada, Dr. Azzam worked in an academic practice where the physicians routinely consulted each other. "Here it is a totally different situation," he said. "We often use PIER to get more information about diseases that we don't see much of, drug information and updates about common medical issues." He particularly appreciates the flags that appear in PIER's disease modules, letting him know about new developments or disease information that's now under review. (Also see, "What's new in PIER.")

PIER evidence, for instance, recently led Dr. Azzam to prescribe ciprofloxacin to a cirrhosis patient who presented with a gastrointestinal bleed—a prophylaxis for bacterial infection. The family physician who had referred the patient wasn't aware of the therapy, which can boost patients' survival rates. "Having the PIER evidence available on my PDA was extremely convenient."

Dr. Tassi has been in practice since late 2004 when he graduated from the University of Western Ontario. He finds himself referring most frequently to PIER's section on procedures, which has detailed information on the procedures covered.

He particularly noted the section on thoracentesis, which contains information and links on managing chronic recurrent malignant pleural effusion. "I find myself reviewing the patient education on thoracentesis and printing the patient information file for patients to read before performing the procedure."

Help with consults

"Where we are, we don't have easy access to fancy investigative procedures and we have to be selective," said Dr. Azzam. "PIER's diagnosis section helps me with what investigations to order." Both doctors have downloaded several frequently used modules—including ones on diabetes, acute coronary syndromes and cirrhosis—in PDF format onto their computer desktops, and use PIER on their PDAs.

PIER helps them decide what screening tests to order—and when those hard-to-access subspecialty consults are really needed. When a 47-year old female patient presented with features of inflammatory arthritis after what initially seemed to be a viral infection, some of her test results were puzzling.

"She had some features of rheumatoid arthritis, but her serum was repeatedly negative for rheumatoid factor," Dr. Tassi said. While he knew that rheumatoid factor is only one of seven diagnostic criteria for rheumatoid arthritis, "the statement in PIER that rheumatoid factor may be present in only 33% of patients with rheumatoid arthritis in the first six months was new to me." He ended up referring the case to a rheumatologist who is still investigating to confirm the diagnosis.

"It's really a great point-of-care system," said Dr. Azzam. "With a quick look you can review the strength of the evidence—and I believe in an evidence-based practice."

Gina Shaw is a freelance health care writer based in Montclair, N.J.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.

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What's new in PIER

PIER recently published its 400th module, providing evidence-based clinical guidance on more than 286 diseases and conditions, as well as information on screening and prevention, ethical and legal issues, complementary and alternative medicine, and common procedures.

PIER has also made changes to the Web site's interface to streamline navigation and provide faster access to content. You can save PIER to your desktop by opening PIER in your Web browser and dragging the PIER icon that appears in the URL address box to your desktop.

The American Academy of Family Physicians has approved PIER as an evidence-based resource for use in continuing medical education applications and programs. PIER is also an approved resource of the National Board of Medical Examiners.

Recently added PIER topics include:

  • Anal cancer
  • Basal cell carcinoma
  • Benign paroxysmal positional vertigo
  • Chest X-ray
  • Chronic pancreatitis
  • Cluster headache
  • Crohn's disease
  • Lasik eye surgery
  • Multiple sclerosis
  • Perioperative management of adrenal insufficiency
  • Pneumocystis carinii pneumonia
  • Renal tubular acidosis
  • Toxoplasmosis

You can access PIER at its Web site or through a link on ACP Online.

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