BeyondtheSE/A

Southeastern/Atlantic Region of the NN/LM

16 Feb 201112-1pm

While the content is in the public domain and no copyright restriction applies, we do ask that users preserve the slides in their current format and cite the

National Library of Medicine as the source.

Bringing the Medical Library to Where It’s Needed – at the

Point of Care

Paul Fontelo, MD, MPHNational Library of Medicine

Bethesda, Marylandfontelo@nlm.nih.gov

Clinical Research RoundtableInstitute of Medicine

Central Challenges Facing the National Clinical Research Enterprise.JAMA 2003;289:1278-1287. http://jama.ama-assn.org/cgi/content/full/289/10/1278

“Medical scientists and public health policy makers are

concerned that the scientific discoveries of the past generation are failing to be translated efficiently into tangible human benefit”

Clinical Research Roundtable Report

Central Challenges Facing the National Clinical Research Enterprise.JAMA 2003;289:1278-1287. http://jama.ama-assn.org/cgi/content/full/289/10/1278

Two major obstacles or translational blocks:

1) impedance to the translation of basic science discoveries into clinical studies

2) block in bringing the clinical studies into medical practice and health decision making

“Making evidence quickly available to clinicians on a busy medical inpatient service using an evidence cart increased the extent to which evidence was sought and incorporated into patient care decisions.”

Sackett DL, Straus SE. Finding and applying evidence during clinical rounds: the "evidence cart". JAMA. 1998 Oct 21;280(15):1336-8.

What is Evidence-Based Medicine?

Clinical problem-solving approach:

• A systematic search of the medical literature

• Critical appraisal of the most relevant evidence to answer a clinical question

• Incorporate own clinical experience

• Patient preferences and values

BMJ 1996; 312: 71-2

The Evidence Cart

• Toshiba Notebook• CD: MEDLINE, Best Evidence, Radiological

Anatomy, Scientific American Medicine, Cochrane Library

• Reprints of the JAMA Rational Clinical Examination series

• Physical examination textbook• Critically appraised topics (CATs) • Redbook (98 topics)• Simulscope

The Evidence Cart

• 81% - affected diagnosis and/or treatment_______________________________________________• 52% - confirmed current or tentative diagnostic or treatment

plans• 25% - led to new diagnostic skill, additional test, new

management decision• 23% - corrected previous clinical skill, diagnostic test, or

treatment_______________________________________________• Perceived need high, but search was only done in 12%

Sackett DL, Straus SE. Finding and applying evidence during clinical rounds: the "evidence cart". JAMA 1998 Oct21;280(15):1336-8.

Utility of Information = Relevance Validity Interactivity

Work to access

Shaughnessy AF, Slawson DC, Bennett JH. Becoming an information master: a guidebook to the medical information jungle. J Fam Pract 1994;39:489-99.

Slawson DC, Shaughnessy AF. Obtaining useful information from expert based sources. BMJ 1997;314:947-9.

Smith R. What clinical information do doctors need? BMJ 1996;313:1062-8.

Access to information at the point of care

• Answers to 77% of 625 clinical questions came from MEDLINE• Changed patient management 47% of the time

Crowley SD, Owens TA, Schardt CM, Wardell SI, Peterson J, Garrison S, Keitz SA: A Web-based compendium of clinical questions and medical evidence to educate internal medicine residents. Acad Med 2003, 78:270-274.

__________________________________________________________

• Use of an online information retrieval system improved the quality of clinicians' answers to clinical questions by 21%

Westbrook JI, Coiera EW, Gosling AS: Do online information retrieval systems help experienced clinicians answer clinical questions? J Am Med Inform Assoc 2005, 12(3):315-21

What clinical information do doctors need?

• Electronic, portable, handheld• Fast, easy to use • Interactive• Answer complex questions• Linked to an electronic medical record• Clinical bottom-line

BMJ 1996;313:1062-1068 (26 October)

Emerging Technologies

• PDA, handheld devices

• Wireless networks

Why mobile phones?

• > 5 billion connections (est. 6B by 2013)*

(World population estimate 6.8B)+

• UN goal in 2000 - 50% by 2015)

• In 2006, 80% lived within MP ranges

• Q4 2010: smartphones 100.9M vs PCs 92M

*GSMA Press release February 2010+GoHive Global Statistics http://www.xist.orghttp://www.bbc.co.uk/news/technology-12337672

Social Networking

http-/www.flickr.com/photos/matthamm/2945559128

+

SIM card

=

GSM phone

You’ve got a phone!

Charges apply only for making calls or sending SMS text messages. No contracts.

Digital Divide?

• “…the answer to that question turns out to be remarkably clear: by promoting the spread …

of mobile phones.”

• “mobile phones raise long-term growth rates

• impact is twice as big in developing nations as in developed ones

– Economist, 3/10/05

Why Mobiles? USA

• *64% of US physicians use smartphones+

• 89% say Internet is essential to practice

(88% Korea, 87% Australia, 81% Europe)• More than 88% use PDAs at least 4x per

day,15% more than 25x per day

• 50% use Wikipedia for information

*Manhattan Research, “Taking the Pulse v9.0”+What is a smartphone? http://snipurl.com/smartfon

PubMed for Handheldspubmedhh.nlm.nih.gov

go.usa.gov/xFb

tinyurl.com/pubmedhhtinyurl.com/pm4hh

20

21

22

Search / results via Internet

Web browser on a MP

PICO

PubMed for Handhelds server NLM PubMed server

(>25% [19-31%] mobile devices)

BMJ 2008,337:a2459

• Plethora of wireless mobile devices -- smartphones tablet computers and portable computers competing for your attention

• What you buy will depend on many factors – your requirements, what your organization supports, network, device functionality, etc

• Read reviews, test devices, ask colleagues on their experience

• There will always be a new device or version coming

PICO Linguist

PICO with Google Translate

1=Not useful 5=Very useful

Number of responses

SMS, text messaging• Worldwide, 4.1 trillion SMS in 2008• Smart Communications (Philippines) reports one

billion SMS per day• US catching up – 363B in 2007 to 1 trillion 2008

(270M subscribers)• One-third of Filipinos have mobile phones

SMS in medicine

• Appointment reminders • Monitoring chronic illnesses (asthma, diabetes,

CHF)• Health messages• Medication reminders, monitoring - DOTS,AIDS• Laboratory test results - Chlamydia• Disease monitoring, alerts (SARS, avian flu)• Consultation, telemedicine

Challenges

• 160-character limit per SMS• Mobile phone screen size

What is TBL?“The Bottom Line”

• a summary of the abstract (an abstract of the abstract)• if structured abstract -> the conclusion is the TBL• if unstructured abstract -> algorithm

Evaluation of TBL Summaries in an SMS Search Interface for MEDLINE/PubMed

01020304050607080

1 2 3 4 5

Agreement score between TBL and full abstract

Nu

mb

er o

f re

spo

nse

s

Clinician (n=1)

Librian (n=18)

Informationist (n=3)

Others (n=4)

(n=329)

Do computer-generated summaries, "The Bottom Line (TBL)" accurately reflect published journal abstracts?Tom O, Fontelo P, Liu F. AMIA Annu Symp Proc; 2007 ;1135. PMID: 18694232.

MEDLINE abstract vs. SMS algorithm (n=95)

0

200

400

600

800

1000

1200

1400

1600

1800#

of

Ch

ars

Original SMS

Word count: 1658 ± 491vs 352 ± 114 Text messages: 11 vs. 3

Outbound SMS Inbound SMS 1/2

2/21/2

http://snipurl.com/1h7md6 evidence2010.com

http://www.bmj.com/content/337/bmj.a3123/reply or http://snipurl.com/1h7nge

Consensus Abstracts - go.usa.gov/xF0

pubmedhh.nlm.nih.gov/consensus.php

Consensus Abstracts - go.usa.gov/xF0http://pubmedhh.nlm.nih.gov/consensus.php

Consensus Abstracts

Consider the abstract not just as a screening tool for finding journal articles but as a resource that could be useful for clinical decision-making

Library-specific URL for PMHh

Near Field Communication (NFC)

- Contactless payment- Transportation- Health

• Healthcare provider/patient location

• Patient visits• Aid to people with disabilities

- Smart object “infotags”

“Good information is the best medicine”

- Michael E. DeBakey, MD

“The Internet allows me to get out of my academic jail.”

- MD in a remote location in a developing country

Paul Fontelo, MD, MPHHigh Performance Computing and CommunicationsNational Library of Medicinefontelo@nlm.nih.gov301.435.3265