Mobile Point-of-Care (MPOC) ToolsMobile Technologies Workshop 16 August 2011

Definition: Point of Care

• Any location where patient care is provided, including, e.g., the bedside, radiology suite, emergency room, clinic, or ambulance

– Taber CW, Thomas CL. Taber's cyclopedic medical dictionary. Philadelphia: F.A.Davis; 1997.

Definition: POC tools• Wide

– All technologies supporting clinicians’decision-making at the point of care• Clinical Decision Support System• Patient Management/Monitoring/Testing• EPR

• Narrow– Patient-side access to the evidence base

through appraised/digested information sources

DiCenso et al, 2009

POC TOOLS

(U) Usefulness of medical information = (R) Relevance x (V) Validity(W) Work

Slawson, D.C. and Shaughnessy, A.F. (1997) ‘Obtaining useful information from expert based sources’, British Medical Jourrnal, 314 (7085), pp.947-949

POC Information Tools: Increased R (physician-led)Increased V (evidence-based)Less W (bedside access; format)

Shared features of POC Tools

• Authoritative syntheses of evidence• Background questions (who, what, when,

where, why, how)• Ease of consultation at the bedside• Regular updates• Multi-platform/format• Extras (e.g. patient info; drug calculators,

CE credits)

Point‐of‐Care Summary Products: A‐Z list ‐ I

1. AccessMedicine (McGraw‐Hill)2. ACP PIER (American College of Physicians)3. BestBETs (Emergency Dept. Manchester Royal Infirmary)4. BMJ Best Practice (BMJ Publishers)5. BMJ Point of Care (USA only)6. Clin‐eguide (Wolters‐Kluwer Health)7. Clinical Evidence (BMJ Publishers)8. Clinical Knowledge Summaries (NHS)9. Clinical Knowledge Summaries Mobile version (CKS Mobile)10. Clinical Xpert Navigator (Thomson Reuters)11. Diseasedex General Medicine (Thomson Reuters)12. Dynamed (EBSCOhost)13. eMedicine (WebMD Health Professional Network)14. eTG Complete (Therapeutic Guidelines LTD)15. EBM Guidelines (Wiley‐Blackwell)16. Essential Evidence Plus (Wiley‐Blackwell)17. First Consult (Elsevier)18. 5‐minute Clinical Consult (McGraw‐Hill)19. Harrison’s Practice: Answers on Demand (McGraw‐Hill)20. Healthgate

Point‐of‐Care Summary Products: A‐Z list ‐ II

21. Info‐Retriever/InfoPOEMS (see Essential Evidence Plus)22. Lexi‐Comp (Lexi)23. Map of Medicine24. Medical Evidence Matters (ProQuest)25. Merck Manuals Online Medical Library (Merck & Co)26. Natural Medicines Comprehensive Database27. Natural Standard28. Nursing Reference Center (EBSCO)29. PEPID30. Psychiatry Online (American Psychiatric Publishing, Inc)31. Royal Marsden Hospital Manual of Clinical Nursing Procedures32. STAT!Ref33. STAT!Ref Point of Care Info (POCi) Primary Care Edition34. Thomson Reuter MicroMedex 2.0 (Thomson Reuter)35. UpToDate (Wolters‐Kluwer Health)36. Wave Medical: International EM Pro (Emergency Doctors)37. Wave Medical: International Primary Pro (General Practitioners)38. Wave Medical: International RN Pro (Registered Nurses)39. Zynx Evidence (Zynx Health)

Choosing POC Tools• Mushrooming product range• Contents

– Scope: volume, breadth, depth; inclusion criteria; extra features

– Editorial policies• Format• Target audience• Costs• User preferences

Evaluation categories• Breadth• Depth• Drug information• Individual author listed• Peer Review• Updating• Keyword• Browse• Drug search• Disclosure/bias

• Ease of navigation• Type of question

answered• Ease of reading• Grading the evidence• Summary of evidence• Bibliography at the end• Links to

PubMed/Athens• PDA applications• EMR integration

Trumble et al, 2006

Raw Evidence Important/Not As Important Levels

ACP PIER ACP PIER ACP PIER ACP PIER

eMedicine Clinical Evidence* Clinical Evidence* Clinical Evidence*

DynaMed DynaMed DynaMed Diseasedex – General Medicine

Clinical Evidence* Clinical Resources @ Ovid eMedicine DynaMed

Clinical Resources @ Ovid eMedicine Diseasedex – General Medicine InfoPOEMS/InfoRetriever

UpToDate UpToDate Clinical Resources @ Ovid Zynx Evidence

Diseasedex – General Medicine

Diseasedex – General Medicine UpToDate eMedicine

FirstConsult InfoPOEMS/InfoRetriever InfoPOEMS/InfoRetriever Clinical Resources @ Ovid

InfoPOEMS/InfoRetriever FirstConsult FirstConsult UpToDate

Zynx Evidence Zynx Evidence Zynx Evidence FirstConsult

Harrison's Practice: Answers on Demand Evidence Matters

Harrison's Practice: Answers on Demand Prodigy Knowledge*

Prodigy Knowledge* Harrison's Practice: Answers on Demand Evidence Matters

Harrison's Practice: Answers on Demand

Evidence Matters Prodigy Knowledge* Prodigy Knowledge* Evidence Matters

Trumble et al 2006

EBP point of care summary scores and ranks (Banzi et al 2010)

Volume Editorial quality EBmethodology

Name

% Rank Score Rank Score Rank

5-minutes consults 83.7 5.5 4 14.5 0 16

ACP Pier 75.5 10.5 9 7 10 8.5

BestBets 53.1 14.5 6 11 15 2.5

CKS 53.1 14.5 6 11 10 8.5

Clinical Evidence 67.3 13 15 1.5 15 2.5Dynamed 87.8 2 11 4 12 5.5

EBM Guidelines 85.7 4 9 7 15 2.5

Emedicine 87.8 2 13 3 1 13eTG 44.9 16 10 5 1 13

First Consult 87.8 2 7 9 1 13

GP Notebook 83.7 5.5 4 14.5 1 13

Harrison’s Practice 79.6 9 3 16 1 13

Map Of Medicine 69.4 12 6 11 12 5.5

Micromedex 75.5 10.5 5 13 11 7

Pepid 81.6 7.5 9 7 2 10

Up to Date 81.6 7.5 15 1.5 15 2.5

Ketchum et al 2011

POC summaries - key points

Implications for practice •No POC product stands out clearly.

•Choice of POC is likely to depend on user preferences – personal weight given to different ranking.

•Users are not likely to use a point-of-care database if it is not easy to use or does not yield answers to their questions.

Implications for policy•POC databases can facilitate effective patient care decision-making by providing information in an easily retrieved, peer-assessed and pre-digested format.

•Adoption recommended:- Involve users- Assess IT infrastructure and support - Consider cost/benefits

Chan and Stieda, 2011

MPOC = SUM of the parts, not any technology ingredient in isolation

Wireless InfrastructureWireless Infrastructure

Mobile DeviceMobile Device

MobilisedMobilisedApplicationApplication

Linking people, process and technology

Mobile Point of Care

Margelis, 2010

http://www.mobilehealthwatch.com

http://www.healthcaregoesmobile.com/

• Unstoppable tide• Readiness to adopt• Improving interfaces• Range of products• Functionalities

Going mobile

http://govnet.msgfocus.com/c/1yVP4ptWRvRz9nhmjR

Going MPOC

• Benefits– True bedside access– Facilitates EBHC– Impact on decisions– Patient safety– Educational tool– Satisfy/empower

staff– Cost savings?

• Challenges– Size/Interface– Hindrance– Reliability– Security– Infection– Training– IT support– Wireless

infrastructure– Which model?– How much? – Who pays (manages)?

Planning for mobility throughout the HC organisation

• Security• Confidential data• Security policies• Encryption• Password access

• Platform• Organisational

strategy• Holistic• One set of

management tools

Usability Network Ethics Management

Mobile screen Bandwidth Privacy Data protection & security

Data entry Coverage Trust Authentication & authorization

Battery life IntegrationIntra-operability

Equity Costs, Return on investment

Contents HardwareIT support

Responsibility of errors

Change management & user training

Marco Isetta marco.isetta@esth.nhs.uk

Epsom and St Helier University Hospitals NHS Trust

References• Banzi, R., Liberati, A., Moschetti, I., Tagliabue, L. and Moja, L. (2010) ‘A

review of online evidence-based practice point-of-care information summary providers’’ Journal of Medical Internet Research, 12(3):e40, pp.1-16. Available online at http://www.jmir.org/2010/3/e26/

• Campbell, R. and Ash, J (2006) ‘An evaluation of five bedside information products using a multi-centered, task-oriented approach’, Journal of the Medical Library Association, 94(4), pp.435-441, e206

• Chan, R. and Stieda, V. (2011) ‘Evaluation of three point-of-care healthcare databases: BMJ Point-of-Care, Clin-eguide and Nursing Reference Centre’,Health Information and Libraries Journal, 28(1), pp.50-58.

• Farrell, A. (2008) ‘An evaluation of the five most used evidence based bedside information tools in Canadian health libraries’, Evidence Based Library and Information Practice, 3(2), pp.3-17.

• Goodyear-Smith, F., Kerse, N., Warren, J. and Arroll B. (2008) ‘Evaluation of e-textbooks. DynaMed, MD Consult and UpToDate’, Australian Family Physician, 37(10), pp.878-882.

• Hauser, S.E., Demner-Fushman, D. Jacobs, J.L., Humphrey, S.M., Ford, G. and Thoma, G.R. (2007) ‘Using Wireless Handheld Computers to Seek Information at the Point of Care: An Evaluation by Clinicians’, Journal of the American Medical Informatics Association, 14(6), pp.807-815

• Honeybourne, C., Sutton, S. and Ward, L. (2006) ‘Knowledge in the Palm of your hands: PDAs in the clinical setting’, Health Information and Libraries Journal, 23(1), pp.51-9.

• Ketchum, A.M., Saleh, A.A. and Jeong, K. (2011) ‘Type of evidence based point-of-care clinical information products: a bibliometric analysis’, Journal of Medical Internet Research, 13(2), e21. Available online at http://www.jmir.org/2011/1/e21/

• Phua, J. and Lim, T.K. (2008) ‘How residents and interns utilise and perceive the personal digital assistant and UpToDate’, BMC Medical Education, 14(8), p.39. Available online at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2483706/pdf/1472-6920-8-39.pdf

• Preddie, M.I. (2008) ‘The Utilization of Wireless Handheld Computers with MEDLINE is an Effective Mechanism for Answering Clinical Questions at the Point of Care’, Evidence Based Library and Information Practice, 3(3), pp.64-67.

• Prgomet, M., Georgiou, A. and Westbrook, J.I. (2009) ‘The impact of mobile handheld technology on hospital physicians' work practices and patient care: a systematic review’, Journal of the American Medical Informatics Association, 16(6), pp.792-801.

• Trumble, J.M., Anderson, M.J., Caldwell M, Chuang, F., Fulton, S., Howard, A. and Varman, B. (2006) A systematic evaluation of evidence based medicine tools for Point-of-Care. Texas Health Science Libraries Consortium, in Proceedings of the 34th SCC/MLA Annual Meeting - 2006 Oct 20–24. College Station (TX): SCC/MLA. Available online at http://www.thslc.org/papers.html

• Wells, L. (2007) ‘Role of information technology in evidence based medicine: advantages and limitations’, Internet Journal of Healthcare Administration, 4(2). Available online at http://www.ispub.com/journal/the_internet_journal_of_healthcare_administration/volume_4_number_2_20/article/role_of_information_technology_in_evidence_based_medicine_advantages_and_limitations.html