Clinical Decision Making in Three Minutes or Less: Information Mastery at the Point of Care

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Clinical Decision Making in Three Minutes or
Less Information Mastery at the Point of Care

• Scott M. Strayer, MD, MPH
• Assistant Professor
• Department of Family Medicine
• University of Virginia Health System

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Outline

• Why do we need clinical decision support?
• What is Information Mastery?
• What are POEMS?
• Determining Relevance and Valididty
• Hunting and Foraging Tools
• Rating your own Hunting and Foraging Tools and
  sandbox time

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Hunting and Foraging Tools

• Foraging
• InfoPoems---www.infopoems.com
• Peer View Institute---www.peerview-institute.org/
• Journal Alerts---www.globalfamilydoctor.com/dailya
  lerts/main.htm

• Hunting
• InfoPoems
• Up To Date---www.uptodateonline.com
• User nameutdprevaafp2004
• Password uptodate
• DynaMed---www.dynamicmedical.com/
• Medscape---www.medscape.com

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Do We Really Need Help With Clinical Decision
Making?Clinical Questions

• Theyre common
• Physician recall 0.1 information needs per
  encounter
• Direct observation 0.5 information needs per
  encounter
• Theyre important
• Only 30 pursued, 75 of those satisfied
• Of those not pursued, half were important
• Journals only used to answer 2 of 1101 questions
  in busy practice (J Ely, BMJ 99)

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Clinical Questions

• Internal Medicine Residents
• 2 for every 3 patients
• 29 pursued
• textbook (31) journals (21) attendings (17)
• Patient expectation, fear of malpractice
  associated with seeking answer
• Lack of time (60), forgot (29).
• Am J Med 2000109218-33.

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The Clinician of the Future

• I know a lot, therefore I am (replaceable by
  a computer)
• I think, therefore I am
• (never replaceable by computer)
• How can we help make this transition?

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Information Mastery in a Nutshell

• Clinically useful information can be defined by
• Usefulness Relevance x Validity
• Work
• Slawson DC, Shaughnessy AF, Bennett JH. Becoming
  a Medical Information MasterFeeling Good About
  Not Knowing Everything. The Journal of Family
  Practice 199438505-13.

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Drilling for the Best Information
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POEM

• Patient-Oriented
• Evidence
• that Matters
• matters to the clinician, because if valid, will
  require a change in practice

Shaughnessy AF, Slawson DC, Bennett JH. Becoming
an Information Master A Guidebook to the Medical
Information Jungle. The Journal of Family
Practice 199439(5)489-99.
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Relevance Type of Evidence

• POE Patient-oriented evidence
• mortality, morbidity, quality of life
• Longer, better or both
• DOE Disease-oriented evidence
• pathophysiology, pharmacology, etiology

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POEMsThe Change Factor

• Vioxx Causes More Heart Attacks and Strokes
• ALLHAT study---HCTZ is best first agent in
  hypertensive patients
• 3 questions
• A. Is it an outcome patients care about?
• B. Is it common to your practice and the
  intervention feasible?
• C. If valid, would it require you to change your
  practice?

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Comparing DOES and POEMs
Shaughnessy AF, Slawson DC. Getting the Most from
Review Articles A Guide for Readers and Writers.
American Family Physician 1997 (May
1)552155-60.
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Validity

• The hard part of Information Mastery
• Technique EBM working group
• Did the researchers find what they think they
  found?
• Do the results apply to your patients?
• Self vs delegation- Take responsibility

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Determining Validity

• Levels of Evidence (LOE)
• 1a, b, c 2a, b, c etc., 5- expert opinion
• A, B, C, D,
• Therapy, diagnosis, prognosis, reviews, etc.
• A moving target

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Treatment Validity Worksheets
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Diagnosis Validity Worksheets
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Work

• Not all information sources are created equal
• Two type of information sources
• Just-in-case sources high work
• Just-in-time sources low work

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Minimizing Work Types of Archived Information
Sources

• Just-in-Case information
• Libraries, Medline, MDConsult, WebMd, MedSites,
  StatRef, other databases
• A superstore of information
• Focus a complete inventory of information
• Benefit Much information is always in stock to
  meet many needs
• Detriments Even the simplest needs require time
  to access the information

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Minimizing Work Types of Archived Information
Sources

• Just-in-Time information
• Highly filtered information sources with rapid
  access
• A Seven-Eleven -- not everything, but quick and
  what you need most of the time
• Focus the best, most commonly needed information
• Benefit Rapid access (less than one minute)
  ease of use
• Detriments Reliance on the filtering mechanism

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Two Tools Needed to Master Information- BMJ 1999

• A method of being alerted to new information (a
  foraging tool)
• A tool for finding the information again when you
  need it. (a hunting tool)
• Without both
• You dont know that new info. is available
• You cant find it when you do
• Clinical example- Riboflavin for migraines
• Shaughnessy AF, Slawson DC. Are we providing
  doctors with the training and tools for lifelong
  learning? British Medical Journal 1999 (13 Nov)
  www.bmj.com. (http//bmj.com/cgi/reprint/319/7220/
  1280.pdf)

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Quality First-Alert Systems

• 1. How is the information filtered?
• Patient- vs disease- oriented?
• Specialty-specific?
• Comprehensive? Which journals?
• Does it matter (change my practice?) or is it
  simply news?
• 2. Is the information valid?
• must have levels of evidence labels
• Beware Trojan Horse!

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Quality First-Alert Systems

• 3. How well is information summarized?
• 2000 - 3000 words accurately in 200 words
• 4. Is the information placed into context?
• Much more than abstracts
• Translational Validity

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First-Alert SystemRisks

• Spyware May be tracking your usage
• Trojan Horse whos paying when its free?
• Abstracts only Journal Watch, Journal Rack, Tips
  from other Journals, Clinical Updates, etc.
• No relevance/ validity filter
• You can have information free and you can have
  it uncensored, but you cant have it both ways.
  No Free Lunch!

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A Few Foraging Tools
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Beware of the Trojan Horse
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A Few Hunting Tools
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Rating Hunting and Foraging Tools
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The Rating Forms

• ..\..\Information Mastery\IM Worksheet
  Foraging_Tool.xls
• ..\..\Information Mastery\IM Worksheet
  Hunting_Tool.xls

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Hunting and Foraging Tools

• Foraging
• InfoPoems---www.infopoems.com
• Peer View Institute---www.peerview-institute.org/
• Journal Alerts---www.globalfamilydoctor.com/dailya
  lerts/main.htm

• Hunting
• InfoPoems
• Up To Date---www.uptodateonline.com
• User nameutdprevaafp2004
• Password uptodate
• DynaMed---www.dynamicmedical.com/
• Medscape---www.medscape.com

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Does it Work?
Physician performance improved (43/65) Drug
dosing systems (9/15) Diagnostic aids
(1/5) Preventive care systems (14/19) Clinical
decision support systems(19/26) Patient outcomes
improved (6/14)
JAMA, October 21, 1998. Vol 280, No. 15, pp 1339
-1346.
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Clinical Support on Your Handheld
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Fines Rule for Pneumonia
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InfoRetriever to help with treatment decisions

• A 46 y/o male, smoker
• PMH significant for hypertension treated with
  HCTZ. Most recent BP 138/86.
• FH Both parents have HTN over age 70, no h/o
  CAD.
• Lipids Chol 197 HDL 41 LDL 141.
• Questions
• What is his risk of an AMI or sudden cardiac
  death in the next 10 years?
• How much will lowering the SBP below 130 reduce
  the risk?
• How much will stopping smoking affect his risk?

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Should his SBP be lowered to lt130?
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What if he quit smoking instead?
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Top 10 Handheld Applications for Clinical
Decision Support

• Drug Reference
• Information Mastery reference
• Avant Go (www.avantgo.com)
• iSilo (www.isilo.com)
• MedRules
• (www.pbrain.hypermart.net)

• Immunization schedule (www.immunizationed.org)
• ABG Pro (www.stackworks.com)
• AHRQ Tools (www.ahrq.gov)
• Textbooks (www.skyscape.com)
• Database Programs (www.handbase.com)