Reviews

Staying afloat in a sea of information: Point-of-care resources

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ABSTRACT

Physicians can use a variety of electronic resources at the point of care to help them make decisions about patient management. The authors address the need for these resources, characterize the elements of good resources, and compare several popular ones, ie, Clinical Evidence, Dynamed, Evidence Essentials, First Consult, Medscape, and UpToDate.

KEY POINTS

  • Today, it seems impossible to keep up with all the information we need, but we can refine our skills in accessing, sorting, and interpreting accurate scientific evidence.
  • The resources reviewed in this article require paid subscriptions except for Medscape, which is supported by advertising.
  • Each of the resources has strengths and weaknesses. For example, UpToDate offers the most topics, but its articles tend to be too long to be practical to read at the point of care.
  • Physicians should familiarize themselves with these resources and use the ones that best suit their needs.


 

References

It is friday afternoon on a sunny July day. The last patient of the day, Ms. Connecticut, is an active hiker who has had Lyme disease previously. She found a tick on her ankle yesterday. She successfully removed the tick but has not brought the tick with her to the appointment. She had been hiking several times over the last week and is not certain when the tick bite occurred. Her question for you centers on the role of antibiotic prophylaxis and Lyme disease prevention.

TECHNOLOGY: PROBLEM AND SOLUTION

Physicians need to keep up with an ever-increasing stream of information—new guidelines, new medications, and updates in medical literature.1 They have to do this while seeing more patients with more chronic problems in less time and while meeting reporting requirements for meaningful use or quality measures for accountable care organizations.

Though some of these challenges are due to technology, one solution is to use technology to our advantage. While researching information in textbooks won’t drain a phone battery, carrying a textbook around is not feasible, and many textbooks (including their electronic versions) contain information that is outdated before they go to print or that is quickly outdated thereafter.2 Further, even online textbooks are currently more dense than the online resources that we review here.

Different types of resources can help task-saturated healthcare providers stay aware of new information while delivering evidence-based care. These tools—online textbooks, decision guides embedded within electronic health record systems, or even a Google search—are termed “point-of-care” resources when used at the time of patient care for decision-making in the moment.

Not all of these resources are of high quality, with reliable factual information. Researchers estimate that up to 70% of clinicians may use Wikipedia to research medical questions, and a comparison of 10 Wikipedia articles vs peer-reviewed sources on the 10 most costly diseases found that 9 of the 10 Wikipedia articles had errors.3,4

In an earlier article,5 we advocated a proactive approach to managing information, highlighting ways to scan for new information and to develop habits of extracting useful information that can then be stored and easily recovered. To complement this strategy and weed out erroneous information, physicians need reliable sources of unbiased information to efficiently answer clinical questions at the point of care.1,6

Here, to help busy clinicians choose which point-of-care resources to use, we review several of the most popular ones, examining their ease of use, key elements, strengths, and weaknesses.

WHAT MAKES A RESOURCE GOOD?

Key features that make point-of-care tools effective include:

Ease of use, with standard formats, a summary for each topic, or both

Links to original articles and concise, capsular summaries and syntheses of the data

Continuing medical education (CME) credit. Tip: when searching, add “CME” to the search string on the browser to access resources that provide this.

Institutional and individual accounts. For clinicians who work for large organizations, point-of-care products may be paid for already, or reimbursement may be available for your subscription. If unsure, ask your director of information technology or library services.

Freedom from advertisements. Many Internet sources have advertisements that either run alongside the information you want to see or, more annoyingly, pop up and require an action to move forward. There is also continuing concern about the effect of industry support on content.7 While not all of the resources that we use regularly and that we review here are ad-free, avoiding programs with high ad content helps limit the possibility of bias and the time it takes to access information. Although advertisements do bring up a risk of bias, resources with a low-level ad content can limit bias while providing free or low-cost access.

Evidence, not expert opinion. Many resources have an “about” page that explains their philosophy and the source of their information. It is vital to be sure that point-of-care databases are providing facts based on evidence.8 This page also typically addresses how authors and editors are selected and whether expert opinion is used when randomized trials are lacking.

Ease of access. Many tools can be accessed not only on computers but also through apps for smartphones and tablets. Some electronic medical records have clinical decision tools embedded in them, with varying capabilities.

Disclosure of conflict of interest. As conflicts of interest can shade recommendations, information sources should clearly disclose financial relationships that could be perceived as conflicts of interest—for example, authors writing about medications sold by companies with whom they have a financial relationship.

NO SINGLE RESOURCE DOES EVERYTHING

Toolbox essentials

There are many types of tools for finding evidence-based medical information. Different tools serve different purposes. Table 1 lists “toolbox essentials” for clinicians needing to answer clinical questions during patient care.

For example, when a question about the need for a bone mineral density measurement comes up, it is useful to be able to quickly compare guidelines from different professional societies on the National Guideline Clearing House. For another example, if a patient brings in a medication in an unlabeled bottle, a pill identifier app can tell you what it is. Clinicians who can use these resources appropriately will be at an advantage in being able to use information to provide better care to their patients.

Point-of-care resources compared

To date, no point-of-care summary source has been shown to be superior in all categories, and use may be driven by ease of navigation, clinician preference, clinical question, or past success.9,10

Reviewed below are several applications that can be used as point-of-care resources (Table 2).

CLINICAL EVIDENCE

Clinical Evidence provides systematic reviews on medical topics. Founded in 1999 by the British Medical Journal, it is available in print as the Clinical Evidence Handbook and in online desktop and smartphone formats.

More than any other source we reviewed, Clinical Evidence addresses not only the evidence that exists, but also the data that do not exist to guide decisions. Compared with 9 other point-of-care resources, Clinical Evidence was found to have the highest quality of evidence.11

Strengths of Clinical Evidence

  • Uncommonly transparent in terms of source of evidence or disclosing when there is a lack of evidence.
  • Clearly lists the strength and relevance of the evidence.
  • Personalization. Users can add notes to articles, save personal searches, and bookmark pages for easy access later.
  • Navigability. Users can easily access systematic reviews, key points, retracted papers, or guidelines.
  • Intuitive organization, with information categorized as research, education, news, or campaigns.
  • New content daily: podcasts, articles, videos.

Weaknesses of Clinical Evidence

  • Limited topics (eg, Lyme disease was not available)
  • The limited content is a challenge when needing quick information at the point of care and may cause most clinicians to use another source unless looking for comparisons of interventions.
  • Cost. Subscribing to the service “on demand,” ie, to look up a single specific topic, costs $36 for 48 hours of access; monthly access or a “season ticket” allows 30 days of viewing of all content for $53. At over $600/year, this is one of the most costly of the sources we reviewed.
  • Marketing of Clinical Evidence to academic institutions that support the service for faculty may limit its appeal to other clinicians.

Next Article:

Channeling the flow of medical information

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