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

DYNAMED

Dynamed, a clinical reference created by a group of physicians, was previously owned by the American College of Physicians and known as Smart Medicine; it is now owned by EBSCO.¹² Reviewers investigate the literature for a given topic and create pithy summaries for busy clinicians. A top feature in Dynamed is its links to full articles cited for best practices or evidence-based guidelines. The company describes their content as free of expert opinion, while being unbiased and evidence-based.

Dynamed uses a 7-step algorithm for searched topics that identifies articles, assesses clinical relevance, evaluates validity of outcomes, compiles the evidence from multiple articles, and then updates the final recommendations daily.

Dynamed Plus, the new upgraded version, updates searched topics several times a day. Dynamed may be the most frequently updated point-of-care resource, with the least risk of conflict of interest, but it offers limited topics drawn from evidence-based findings.^11,13–15

With the rapid doubling of the medical literature, frequent updates allow clinicians to be most current with practice guidelines. This potentially affects quality of care for antibiotic use, vaccination, health promotion, and screening as well as newly approved medications.

Strengths of Dynamed                                                               

• Large collection of topics, critically appraised, written for primary care physicians, presented in bulleted format
• The most frequently updated database^11,14,15
• Can integrate with major electronic health records (eg, Epic, Allscripts, NextGen, Cerner)
• Has an area devoted to new information that changes current practice
• Chosen topic grouped with related topics in the differential diagnosis after the initial search
• Easy-to-read outline for quick access to information such as billing, diagnosis, and references
• Medical calculators
• No advertisements
• Helpful embedded tools
• Icons to print or email the article
• An icon to create a “perma-link” to topics, searches, and browse categories
• Graded evidence with a link to the grading model used
• Links to primary articles
• Patient information handouts
• Alerts for updated information
• CME credit
• Special consideration and features for medical education
• The upgraded version Dynamed Plus contains Micromedex for a medication database, expanded graphics, semantic search, concise overview for each topic, and expanded content.

Weaknesses of Dynamed

• Although the topic list is large, it is only about one-third the size of UpToDate.
• A subscription for a physician costs $395 a year. Residents can sign up for about $150, and students for just under $100.
• CME is obtainable but cumbersome; one submits the CME credits through Tufts Healthcare, which requires a second sign-on to access and track.
• Drug and nondrug treatments for diseases cannot be separated.
• Useful calculators include decision trees for clinical decision-making, but there is no way to search them—one must waste time scrolling  through the topics and specialties looking for desired information.
• Major shortcoming: there is no medication reference tool unless you upgrade to Dynamed Plus.
• The expanded graphics of Dynamed Plus are difficult to view on mobile applications within the articles (they are brought up more reliably when searching just for the image).
• The use of strict evidence-based methodology without expert opinion is a strength, but limits the collection of topics without randomized controlled trials, for which turning to expert opinion may be the only option.

EVIDENCE ESSENTIALS

Evidence Essentials is a point-of-care resource from Wiley that offers a variety of content types. The website lists 13,000 medical topics; however, they are not all summary reviews as discussed in the other products above. Subject matter is reviewed 3 times a year. Comprehensive reviews number just under 800 individual topics, with the remaining content consisting of Cochrane reviews, calculators, decision support tools, POEMs (Patient-Oriented Evidence that Matters), evidence-based medical guidelines, and dermatology images (1,000).

Evidence Essentials provides some unique content including a quick evaluation and management (E/M) code-finder and calculators not only for the typical medical equations, but also for history and physical examination likelihood ratios and pretest probabilities, which are practical and an excellent teaching aid. It also offers CME along with POEMs, e-mail alerts, and a listing of upcoming topics.

Strengths of Evidence Essentials

• Relatively inexpensive at $85 a year.
• High-functioning filter system to choose to search one or multiple databases.
• Related results are listed for aid in differential diagnosis, similar to Dynamed.
• Authors, editors, and date of last review are highly visible. As in UpToDate, relevant medical calculators appear on the page.
• The likelihood and odds ratio calculators are a huge plus for clinical decision-making and putting guidelines into practice.
• “Overall bottom line” highlights key points
• Grading of evidence per topic.
• Bulleted and tabbed information for quick access.
• Tabs for information on background, prevention, diagnosis, treatment, references, guidelines, and special populations.

Weaknesses of Evidence Essentials

• Limited number of topics with comprehensive reviews.
• While you can click on any drug name and link to a choice of two drug databases, this is not included in the subscription and requires a second account.
• The resources tabs had some broken links. In our clinical example, the tab contained several videos at the top that were not related, followed by a map and tables that were relevant to Lyme disease.
• Likewise, some of the guideline references were disappointing. For example, the guideline link for Lyme disease is for the US Department of Labor Occupational Safety and Health Administration rather than a professional society.
• For the provider wanting a narrative, this is more of a bare-bones text.

FIRST CONSULT

First Consult is Elsevier’s point-of-care clinical decision product contained within ClinicalKey.

Unlike UpToDate and Dynamed, in which authors and editors read original articles and summarize or synthesize information for the learner, First Consult is a “smart” search engine that will research a question, together with associated terms and key words. Filters such as full-text availability, journal articles, and patient education can be applied.

You may need to read about your topic in a textbook first, and then, if you are looking for treatment information, find an original article through First Consult. It is available in mobile and desktop formats, and the point-of-care product, First Consult, has an app that can be downloaded and used for free for the first 60 days.

Importantly, the First Consult portion of ClinicalKey with the summary topics was rated by Shurtz and Foster¹³ as least current of the products we are discussing in this article. On the other hand, it was the only product that had an embedded program to assist the user in making presentations by allowing drag and drop of images and automatic citing of sources. Kim et al report that First Consult is one of the resources providers prefer.⁹

Strengths of First Consult

• Lengthy free trial
• Ability to access original articles from a list vs lengthy narrative
• Access to journals and books published by Elsevier
• Powerful search engine that applies associated terms automatically
• Patient education is available in different languages and font size with the ability to add instructions and even a local branding
• Can integrate with electronic health record
• Can filter results by guideline, patient education, topic overviews
• Presentation assistance.

Weaknesses of First Consult

• Time-intensive. A provider needing quick advice on treatment for a medical condition has to guess if an article or textbook will have the most up-to-date and digestible information, whereas this has already been summarized in other products. For the busy clinician, this may be prohibitive.
• Search results are limited to Elsevier products, and major journals such as the New England Journal of Medicine are not available.
• Inconsistent platform functionality. The app version was somewhat “sticky” to use, as pages did not always load efficiently, and the menu bar navigation is not ideal.
• Expensive, especially given cheaper alternatives. For example, subscribing to the specialty of internal medicine or family medicine costs $499 and provides access to 8 journals and 11 books. Extended access costs $998 and offers full-text access to 23 books and 45 journals. The complete service has a total of 400 journals, 700 books, and 2,500 procedural videos.