The wife of a 72-year-old man heard about the benefits of vitamin D on The Dr. Oz show. So she started giving a bunch of it to her husband, who in turn developed constipation and “was just not acting like himself,” according to Sameer Badlani, MD, FACP, who saw the man in clinic.
The man, who had a medical history of hypertension, was admitted to the hospital from clinic for hypercalcemia (11.2 mg/dL) found on routine labs, along with an elevated phosphate (6.2 mg/dL) and a low albumin (3.0 mg/dL). The patient took 40 mg daily of lisinopril and his brother had prostate cancer, but there was no other family history of malignancy.
“So here I am, I sort of remember that albumin has a correlation with calcium, but how do I know this is really hypercalcemia before I start giving him IV fluids or bisphosphonates?” asked Dr. Badlani, a hospitalist and chief medical information officer at the University of Chicago, during an Internal Medicine 2013 session on using technology in clinical practice.
In situations like this, a medical calculator can come to the rescue, helping to determine the effective serum calcium value for the patient. “I would go to MDCalc.com,” Dr. Badlani said. “I type in the patient's values, and it tells me this is definitely a real hypercalcemia.”
During the fast-paced, interactive session, Dr. Badlani and two colleagues reviewed many other popular software applications, as well as particularly useful features of electronic health records. Audience members were encouraged to use their mobile devices to text questions and answer polls, results of which appeared instantly on one of two screens in the front of the room.
Continuing with his patient with hypercalcemia, Dr. Badlani said he would use ACP's Physician's Information and Education Resource (PIER) to determine what to do next. “I go to PIER, to the diagnosis section, then ‘laboratory and other studies' and it provides a useful table” that describes the tests one can order to get more specific information about the patient's condition, he said.
Another benefit of PIER is that it lists when each module was last updated, which helps if you know that a practice-altering study has recently been published on the topic. It also specifies the level of evidence supporting its recommendations. Dr. Badlani demonstrated the latter function on-screen for session attendees.
“You see this little ‘A’ at the end of the line? This means the evidence is based on a randomized, controlled trial. I don't know about you, but I always like to see the letter ‘A.’ Getting a ‘B’ in my family was like having a learning disability. So, click on the ‘A’ and you get more information about the research,” he said.
Other clinical decision-making resources that clinicians might use on the wards include UpToDate, Dynamed, STAT!Ref, MD Consult/First Consult and Pocket Medicine, noted Jonathan Pell, MD, a hospitalist and IT physician liaison at University of Colorado.
When you've got an hour or so to dig deeper into a subject, good resources include Google Scholar, PubMed-Medline, WebMD, Medscape, Cochrane Library and online textbooks, he added.
“Wikipedia and Google are getting used more as their functionality gets better,” Dr. Pell noted.
Dr. Badlani said, however, that Wikipedia should not be used for medical decision making. “I really discourage interns from using Wikipedia,” he said. “It's like having a baby and letting them drink soda in their first year.”
Calculators and tools
Aside from clinical knowledge bases, the biggest categories of software apps used by physicians are medical calculators, medication tools and antibiotic tools, said Dr. Pell.
In informal polling of colleagues, as well as residents and attendings at his hospital, Dr. Pell found the five most commonly used medical calculators were MedCalc Mobile, QxMD, Mediquations, MediMath, and Medical Calculator. “Use of medical calculators is definitely on the rise,” Dr. Pell said.
In an instant poll during the session, about half of the audience indicated they use antibiotic apps on a regular basis. While there are several mobile antibiotic management applications on the market, the Johns Hopkins Antibiotic Guide and the Sanford Guide received the highest scores for content and usability in an evaluation by three infectious disease specialists that was published in Clinical Infectious Diseases, Dr. Pell said.
“A lot of us also have pharmacy or med apps on our phones,” Dr. Pell noted. The six most popular are Micromedex, Lexicomp, Epocrates, Medscape, UpToDate online and Skyscape (RxDrugs), he said.
Optimizing your EHR
“In the inpatient setting, pre-rounding reports that capture and summarize data obtained in the last 24 hours are critical,” Dr. Pell said. Dashboards also are useful to monitor one's patients in real time throughout the day, while medication/condition flow sheets give more detailed and organized information on patients to see trends over time and responses to therapy, he added.
“Work with your IT physician representatives to optimize the content and format of these tools,” he advised. “Part of our job is to push our IT departments to make sure they are giving us what we want,” he said.
As for embedded clinical decision support, find out what tools are available in your EHR and customize when possible, Dr. Pell said. “Billing calculators are relatively new and have been built in. These are not necessarily for residents but they can help with the complex system of billing at different levels,” he said.
Other options are alerts for patient allergies that can steer you to appropriate medication alternatives, auto-populated note templates, orders with embedded patient information, and alerts with direct links to actionable items, Dr. Pell said.
Use technology wisely
Using apps and gadgets to help with diagnosis and management is great, but employing them during patient encounters can be tricky, noted C.T. Lin, MD, FACP, the chief medical information officer at University of Colorado Health.
“You want to engage the patient in the use of the computer through triangulation. Invite the patient to review information on your computer or mobile device. Have them sit side by side with you. Verbalize what you are you doing on your device in the presence of the patient,” Dr. Lin said.
Some patients may feel a little uncomfortable with the technology at first, so you can ease them in with something simple, like looking up the last progress note, or the results of a blood test, he said.
“I had a patient who never quite got the [hemoglobin] A1c concept until she saw the red line for ‘normal,’ and that she was above it,” Dr. Lin said.
Things you shouldn't do in front of patients include complaining about technology, he added.
“Don't go on about how slow the network has been all day. In the patient's eyes, it just reflects poorly on you for choosing that network,” Dr. Lin said.
Also, don't write notes on the computer in front of your patient without asking permission. Jotting down short phrases, which can be fleshed out later, is a good strategy, he said.
And of course, you should also remember to log out of applications that contain protected patient information, refrain from sending SMS/texts or unsecured emails with protected patient information, and avoid putting patient information on a device that isn't password-protected or encrypted, he said.
Cloud-based technology is not yet considered mature for the healthcare vertical, said Dr. Badlani. “I would advise you to have your [information technology] department do a full security analysis, including a HIPAA audit, before implementing cloud-based technology solutions,” he said.