EBM Point-of-Care ResourcesMercer University School of Medicine Medical Libraries

Best Research Evidence

Clinical Expertise

Patient Values

EBM

What are Point-Of-Care Resources?Many research studies have looked at the

obstacles doctors face when trying to find evidence to answer questions that arise during clinical practice.

A 2002 BMJ study by John Ely and others identified over 50 barriers doctors encountered while searching for patient care information.

Point-of-Care information tools attempt to address some of these problems. These clinically-focused resources emphasize diagnosis and treatment.

BMJ. 2002 Mar 23;324(7339):710. Obstacles to answering doctors' questions about patient care with evidence: qualitative study. Ely JW, Osheroff JA, Ebell MH, Chambliss ML, Vinson DC, Stevermer JJ, Pifer EA.

Point-of-Care Choices

There are a lot of different Point-of-Care Resources available.

Some are free, some require a yearly subscription fee.

Point-of-Care ChoicesSometimes an institution will purchase

access to Point-of-Care resources.For example, Mercer University School of

Medicine has purchased access to: AccessMedicine; Cochrane Library Full-Text; ClinicalKey; Dynamed; Essential Evidence Plus; Facts & Comparisons; and Micromedex

Memorial University Medical Center & MCCG have purchased access to: UpToDate and Micromedex

The Georgia Dept. of Public Health has purchased access for all hospitals in Georgia to: VisualDX

Point-of-Care ChoicesFree resources include: ACP PIER

(free to members and students); TRIP; Google Scholar; PubMed; PubMed Health; SUMSearch; eMedicine/Medscape; National Guideline Clearinghouse; USPST ePSS Tool; Drug Information Portal; Drugs@FDA; Archimedes; and Calculate by QxMD

Point-of-Care ChoicesCheck with your institution to see

if they provide access to subscribed Point-of-Care Resources.

If they don’t, or don’t provide access to the ones you want, information regarding personal subscriptions is provided on the EBM Point-of-Care Chart

http://med.mercer.edu/library/capstone.pdf

Resource TypesDeciding to use a Point-of-Care

resource is like deciding to buy grits at the grocery store.

It seems easy enough…

Resource TypesBut it can get complicated…

You get to the store and there is an entire aisle devoted to grits.

Resource TypesThere are quick grits….….and regular gritsYellow grits….….and white gritsStone ground gritsGrits in bags and grits in boxesWhat do you do!!!!

Resource TypesAssess your needs. If you don’t

have much time to make your grits, you may want to get the quick grits. You may be sacrificing depth of flavor and texture for speed.

If you want the very best grits experience, you may want to go with a fancy stone ground variety… with whole milk and land o lakes butter.

Resource TypesIt is the same way with Point-of-

Care resources.Assess your needs.

Resource TypesThere are different types of Point-of-Care

resources that can be used for various circumstances:◦ Systematic Reviews (stone ground grits with whole

milk and butter)◦ Critically Appraised Topics (quick grits)◦ Unfiltered Resources (regular grits)◦ Textbook Style Information (big bag of grits)◦ Guidelines (small box of grits)◦ Drug Information that enables EBM (cheese in cheese

grits)◦ Medical Calculators (timer for the grits)

The different types of Point-of-Care resources are represented in different colors on the EBM Point-of-Care Chart

http://med.mercer.edu/library/capstone.pdf

SYSTEMATIC REVIEWS

The highest level of evidence on the EBM Pyramid of Evidence is Systematic Reviews

Systematic ReviewsSystematic Reviews are literature

reviews that use rigorous, systematic, and transparent methods to minimize bias in the results.

They provide the decision-maker with the best available evidence.

They are like fancy stone ground grits with whole milk and land o lakes butter.

Systematic ReviewsCochrane Reviews are systematic

reviews of primary research in human health care and health policy, and are internationally recognized as the highest standard in evidence-based health care.

Systematic ReviewsEach Cochrane systematic review

addresses a clearly formulated question; for example: Can antibiotics help in alleviating the symptoms of a sore throat? All the existing primary research on a topic that meets certain criteria is searched for and collated, and then assessed using stringent guidelines, to establish whether or not there is conclusive evidence about a specific treatment.

Systematic ReviewsThe Cochrane reviews are updated regularly,

ensuring that treatment decisions can be based on the most up-to-date and reliable evidence.

Use Cochrane to find the highest level of evidence for patient care or health policy.

The Cochrane abstracts are free, the full-text requires a subscription.

Systematic ReviewsPubMed Clinical QueriesSpecialized PubMed searches to

retrieve citations identified as systematic reviews, meta-analyses, reviews of clinical trials, evidence-based medicine, consensus development conferences, and guidelines.

Systematic ReviewsUse PubMed’s clinical queries to

select systematic reviews from the MEDLINE database.

PubMed citations are free..

PubMed HealthBased on systematic reviews of clinical trialsUse these clinical effectiveness reviews to

see what treatments and prevention methods have been proven to work – and what remains unknown.

PubMed Health is free.

Critically Appraised TopicsExpert/s search the primary literature

and select information to be presented in a resource as a topic.

What you are seeing is information that has been chosen by the expert/s, not all of the literature available.

Critically Appraised TopicsFor example, there are a lot of

point-of-care resources available. What you are seeing in this presentation is what Carolyn and Carolann have selected for you to see, not everything that is available.

Critically Appraised TopicsInformation on a topic

is usually divided up into sections such as General Information, Causes and Risk Factors, History and Physical, Diagnosis, Treatment, Prognosis, Prevention and Screening, Guidelines, and Patient Information.

Critically Appraised TopicsRecommendations for patient care are

provided.Sometimes references to the primary

literature are provided.Sometimes EBM levels of evidence are

provided.

Critically Appraised TopicsThese are like quick grits.Use these resources to find quick

answers to clinical questions for patient care.

Remember: these resources provide selected information, chosen by expert/s.

You may be sacrificing depth of flavor and texture for speed.

Critically Appraised TopicsDatabases include: ACP PIER;

Clinical Evidence; ClinicalKey (FirstConsult); Dynamed; Essential Evidence Plus; PEPID; TRIP; UpToDate; VisualDX.

Unfiltered ResourcesThis is where the experts who do

the critically appraised topics in resources like UpToDate, Dynamed, PEPID, ACP PIER, etc. get their information.

Unfiltered ResourcesThe experts select their information from

these unfiltered resources that help you search for primary literature such as RCTS, Systematic Reviews, Case Reports etc.

Unfiltered ResourcesThese resources are like regular

grits. You may find more depth of flavor, but it may not be quick.

Use these unfiltered resources to find more in depth information that is not provided in resources such as Dynamed or UpToDate.

Unfiltered ResourcesUse unfiltered resources

when you have questions about the information provided by an expert and want to see the primary literature for yourself.Also, use unfiltered resources to find information that is so new that it may not have been synthesized into a database yet.

Unfiltered ResourcesThe physician is sitting down with

liquid refreshment because it may take some time to search through unfiltered resources.

Unfiltered ResourcesUnfiltered Resources include:

ClinicalKey (articles); Google Scholar; PubMed; SUMSearch.

Textbook Style InformationResources that provide access to online

textbooks or information that is presented in a textbook format.

Use these for in depth background/overview information.

These are like a big bag of grits. There is often a lot of information (ie Boron!)

Textbook Style InformationResources include:

AccessMedicine; ClinicalKey (eBooks); eMedicine/Medscape

GuidelinesGuidelines are statements by which to

determine a course of action. They are best used to help make

decisions about appropriate health care for specific clinical circumstances.

They are like a small box of grits (called polenta on the box). They have focused information.

GuidelinesGuidelines are included in resources such as

ClinicalKey, Dynamed, and Essential Evidence Plus.

Guideline specific resources include: National Guideline Clearinghouse and U.S. Preventive Services Task Force (USPSTF) ePSS Tool

GuidelinesYou can use

the Guideline and/or Practice Guideline filter in PubMed to limit your PubMed results to just guidelines.

Drug InformationQuality drug knowledge

resources, optimally integrated into clinical workflow, enable EBM

They are like the cheese in cheese grits. They can enhance and transform the grits experience.

Drug InformationTo facilitate

EBM, drug databases must be accurate and reliable; comprehensive; timely, and updated frequently.

Drug InformationUse these resources to find

information about a drug, side effects, drug interactions, warnings, dosage, patient information and more.

Drug InformationResources include: Drug

Information Portal; Drugs@FDA; Epocrates; Facts & Comparisons; and Micromedex.

Medical CalculatorsMedical Calculators

help you to evaluate situations and through them reach informed decisions.

They are like a timer for your grits. They help you to evaluate the cooking of your grits.

Medical CalculatorsCalculators can be used to determine

risk scores, likelihood of disease, and diagnostic tests.

Use them to determine a patient’s body mass index, predicted peak flow, gestational age or other clinical parameters.

Use the Critical Appraisal of the Evidence Stats Calculator to calculate statistics in articles to evaluate them.

Medical CalculatorsResources include: Archimedes;

Calculate by QxMD; Critical Appraisal of the Evidence Stats Calculator; Essential Evidence Plus; and Mediequations

Suggested Possible Starter Kit for a Mobile DevicePubMed (there are a number of PubMed apps; a

popular one for iPad is PubMed Clip; $2.99)Dynamed ($149.95 for residents) or Essential

Evidence Plus ($85.00) or PEPID Primary Care (Family Medicine; $264.95) or ACP PIER (Internal Medicine; $109.00 for residents)

U.S. Preventive Services Task Force (USPSTF) ePSS Tool (free)

Medscape (free)Epocrates Essentials ($159.99)Calculate by QxMD (free)

These choices are our own suggestions and are not endorsed by Mercer University School of Medicine. Opinions will vary a lot.