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

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Reliable medical answers are only a click away

From the September ACP Internist, copyright © 2009 by the American College of Physicians

By Paula S. Katz

Using the Web during a patient’s visit can yield evidence-based answers and improve quality of care, according to Benjamin Krevsky, FACP, MPH.

“[Going online] adds a little extra time to the patient encounter but we get the answers right now, provide better care, and improve our knowledge base because we’re using the information in real time,” said Dr. Krevsky, a professor of medicine and director of gastrointestinal endoscopy at the Temple University School of Medicine in Philadelphia.

Some physicians say there’s not enough time during patient visits to go online. Others doubt they’ll find useful information or fear they will find too much. But physician-oriented search sites—what Dr. Krevsky called the physicians’ new generation of tools—make evidence-based information quickly available to busy clinicians.

“It’s important to access association Web sites or others that are peer-reviewed, not Aunt Mary’s blog,” he said during a session on evidence-based answers at the point of care. The trick is knowing how to choose and navigate these sites. Dr. Krevsky spoke at Digestive Disease Week but cited resources applicable to any physician specialty.

Best sites

Point-of-care sites that work well share common characteristics: comprehensive topic coverage and specific information that can be applied to patient care, detailed treatment recommendations with full prescribing information, evidence-based rationale for the recommendations, practical treatment recommendations, authoritative resources, and regular updates, said Dr. Krevsky, citing a 2005 Journal of the American Medical Informatics Association article.

He encouraged attendees to access sites that include user-friendly, intuitive search functions that are clinically based rather than disease oriented, and are fast and easy to access.

PogoFrog, which is a version of Google just for physicians, is one of Dr. Krevsky’s favorites because it cuts through the online clutter. For example, he said a regular Google search about viral causes of diarrhea in students going to Mexico yielded 90,000 hits; the same search on PogoFrog gave him just 10.

Another free service is eMedicine from WebMD that includes articles on 7,000 diseases and disorders plus practice guidelines for 39 medical specialties. It boasts regular updates from 10,000 contributors.

He also likes PIER, ACP’s decision support program, especially for patient follow-up. For example, he accessed it to find out when a patient with diverticulitis should be seen in follow-up, when that patient should get a colonoscopy and if he should be on a high- or low-fiber diet. “This is especially nice to print out for residents, fellows and referring doctors,” he told ACP Internist during a later interview.

PIER is free to ACP members, and Dr. Krevsky noted that it may be all that most members need for point-of-care information. “It’s really clean, uncluttered, and easy to drill down to the core information that I’m looking for. The patient information and CME are also real pluses,” he said.

Here are other top fee-based point-of-care sites, according to Dr. Krevsky. (Some allow hospitals and practices to buy site licenses.) Some sites also include mobile device access. Check individual sites for specific details.

  • Access Medicine includes more than 50 medical titles (like Harrison’s Online), updated content, thousands of images and illustrations, interactive self-assessments, case files and diagnostic tools.
  • ACP Medicine is an online medical textbook that covers 11 internal medicine subspecialties.
  • DynaMed includes 3,000 clinical topic summaries based on more than 500 medical journals and systematic review databases using journal review services. It’s updated weekly by e-mail.
  • Essential Evidence Plus offers access to patient-oriented evidence, clinical decision rules, Cochrane reviews and guidelines.
  • First Consult/MD Consult provides continuously updated files on more than 475 medical conditions and a differential diagnosis tool organized by chief complaint. Dr. Krevsky said he likes the site because of its guidelines and full textbooks.
  • Ovid includes hundreds of databases, more than 1,200 journals, books from dozens of publishers and regular updates.
  • UpToDate offers evidence and recommendations for 7,300 topics written by more than 3,600 experts. It’s continuously updated. Dr. Krevsky said he likes the site because it offers the most detail.

How it works

To show attendees how to put the sites to work, Dr. Krevsky walked them through some examples.

One case involved a 69-year-old man with hepatitis C cirrhosis without a history of variceal hemorrhage who was noted to have large varices on upper endoscopy. To find out the preferred therapeutic agent for the prevention of variceal bleeding, Dr. Krevsky searched for “esophageal varices” on MD Consult. The first result from the search, “Esophageal varices—Medical Topic,” was a winner, he said. Clicking on it brought up a summary describing esophageal varices and their prevention and treatment. The answer to Dr. Krevsky’s question was easily found in the bulleted list of information: “The nonselective agents propranolol and nadolol are first choices.”

In another case, Dr. Krevsky used PIER to find how to manage a patient with an upper gastrointestinal bleed given a particular endoscopic finding of a visible vessel present in the base of an ulcer. After entering “bleeding” in PIER, he was given a list of information types to choose from. By clicking on “therapy,” he was easily able to find what he wanted in the sixth result: “Disease—Gastrointestinal Bleeding, Non-variceal Upper—Non-drug Therapy.” Clicking on that link led to clear guidelines on how to manage the patient using endoscopic therapy.

Each site has its own way of sifting through information. For example, Dr. Krevsky showed the audience how to access an alphabetical list in DynaMed to find answers about complications of Barrett’s esophagus. He also led attendees through a PogoFrog search to find out the second most likely cause of diarrhea (see sidebar). When he queried “traveler’s diarrhea and students,” his first result led him to the answer.

Encouraging results

Given their ease of use, it’s no surprise that access to point-of-care tools leads to changes in practice. Dr. Krevsky cited a study (Schilling LM, et al. Acad Med 2005; 80(1):51.) showing that physicians who had access to a range of point-of-care online tools, including UpToDate, ACP Journal Club PLUS and others, had 89% of their questions answered; 78% of the answers changed patient care. That’s a huge improvement over current practice in which only 30% of questions get answered by looking in a textbook or asking a colleague, according to Dr. Krevsky.

These tools also help busy physicians keep up on medical information. Studies show that retention is 90% when information is used immediately at the point of care, versus 75% when learners practice what they learned and just 5% when they learn only from lectures, Dr. Krevsky said. He also noted that 17% of physicians fail the American Board of Internal Medicine recertification exam and 10% fail the gastroenterology recertification exam the first time.

“Our challenge, believe it or not, is that we can’t remember everything,” he said. MEDLINE—not a point-of-care tool but a comprehensive database that offers clinical queries—adds 1,500 new articles every day, he pointed out. “It is simply impossible for anyone to keep up with every new article.”

Incorporating the searches into practice can be simple. Dr. Krevsky has a computer in each examination room. “I’ll say, ‘Let’s look [your question] up and compare the information you brought in to what else is out there.’” For the final touch, he prints out that information for the patient when he can get it in lay language.

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Try it yourself

How comfortable are you searching for medical information you can trust online? Use the following examples by Benjamin Krevsky, FACP, MPH, to try your hand. (The suggested online tools in parentheses are ones Dr. Krevsky used during a presentation at Digestive Disease Week.)

1. Based on current data, what is the best estimate of the annual risk for developing adenocarcinoma in patients with Barrett’s esophagus? (Try DynaMed, a fee-based service that offers a free trial by registering.)

a. 50%

b. 25%

c. 5%

d. 0.5%

e. 0.05%

2. An 18-year-old previously healthy man presents with diarrhea following a trip to Mexico at spring break. What is the second most likely cause of diarrhea (after enterotoxigenic Escherichia coli )? (Try PogoFrog.)

a. Enteroinvasive E. coli

b. Shigella flexneri

c. Norovirus

d. Giardia

e. Entameba histolytica

Answers: 0.5%; Norovirus

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