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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?