Here’s why you should be using a point-of-care tool at the bedside

A Joule interview with Dr. Eddy Lang and Dr. Alan Ehrlich from DynaMed Plus

If you’re overwhelmed by the variety of clinical information tools available to physicians these days, you’re not alone. With all the free or subscription-based online resources and apps currently available, it’s not always clear what differentiates each tool or where to go for the most current and evidence-based recommendations. The reality is that clinical knowledge is growing at an unprecedented rate―one new medical or scientific publication occurs every 30 seconds. Public databases reportedly have over 50 million medical and scientific publications available and counting.

An audit of a 24-hour medical intake in an acute care hospital that included 44 diagnoses correlated to 3,679 pages of national guidelines and 122 hours of reading.1 You don’t need to be a physician to know that’s just not feasible.

We spoke to Dr. Alan Ehrlich, Executive Editor at DynaMed, and Calgary-based Dr. Eddy Lang, Recommendations Editor at DynaMed, to learn more about DynaMed Plus and why you should be using this tool as a first stop at the bedside. We got their perspectives on how you can be more efficient with your time without compromising quality of care.

Dr. Ehrlich, Dr. Lang, thank you both for agreeing to speak with us. To begin with, can you tell us a little bit about your backgrounds and how you got involved with DynaMed?

A.E.: I am a family physician and have been part of a large multispecialty group practice for the past 25 years. I am currently doing urgent care work for our group to accommodate my time in editorial work at DynaMed. Prior to coming to DynaMed, I had been an Associate Editor for the 5-Minute Clinical Consult. I came to DynaMed to become more involved with promoting evidence-based medicine.

E.L.:  I’ve been teaching about evidence-based medicine for a number of years now. Much of that focus has been about finding the best way to integrate the best evidence at the bedside efficiently and readily into workflow. Lately, I have been doing a great deal of work with several organizations who have moved to the GRADE system for developing clinical recommendations. Cochrane (formerly Cochrane Collaboration), WHO and the CDC are among the many users. When I found out DynaMed was moving to a GRADE approach, I was keen to learn more and eventually joined the team of recommendation editors. They review key recommendations to ensure that they are in keeping with GRADE and are, for the most part, not overly enthusiastic of an uncertain evidence base.

Figure 1: DynaMed Plus methodology for clinical recommendations
Figure 1: DynaMed Plus methodology for clinical recommendations

Prior to becoming editors, were you using DynaMed or other point-of-care tools in your practice?

E.L.: Yes, as both a clinician and an educator. I would like to highlight its capabilities around clinical scenarios that lend themselves to evidence-based answers and, usually in some sort of e-classroom setting, highlight how DynaMed features key clinical actions―especially through the “overview and recommendations” section―which is a carefully honed synopsis of essential guidance.

Figure 2: Overview and recommendations section
Figure 2: Overview and recommendations section

A.E.: I was not a regular user of DynaMed before joining the editorial team. I had been serving as an Associate Editor for a textbook with an online application and tended to use that, although I used a variety of resources. This included online resources, apps on my Palm Pilot (it was that long ago!) and of course, textbooks. Textbooks were useful for things that did not change a lot, such as dermatology images or instructions on how to do certain procedures. However, as online resources―and subsequently on-the-phone resources―became better, the use of textbooks largely faded away.

Why is it so important to have practicing physicians such as yourselves as contributors?

A.E.: I view myself as both a producer and user of DynaMed Plus content. By using it on a regular basis in my practice, I quickly become aware of the types of questions we need to make sure we are answering, and how well we are doing at that task. I am always assessing how quickly I can find the answer to my question in a real-world setting, not just as an academic exercise. I am also able to see where there is a need for information in areas where the evidence base may be weak, but there are clinical questions that come up.

"By using it on a regular basis in my practice, I quickly become aware of the types of questions we need to make sure we are answering, and how well we are doing at that task. I am always assessing how quickly I can find the answer to my question in a real-world setting, not just as an academic exercise."

E.L.:  I think it helps to contextualize much of the content. For example, we can have a number of great randomized controlled trials (RCTs) and a systematic review related to a given intervention but if there are issues related to feasibility, acceptability to patients or MD training requirements, we can bring these into focus―also, from an evidence-based vantage point.

At Joule, we get a lot of questions about whether DynaMed Plus is a Canadian tool. It’s not―but we know that DynaMed Plus includes Canadian guidelines, surveillance of Canadian medical journals, Choosing Wisely recommendations and has Canadian editorial staff. Can you please speak to this and how this sets you apart from other tools?

A.E.: We are very aware that we have an international audience, and we keep that in mind when creating content. While US guidelines are highly regarded, the practice of medicine does vary from country to country based on factors such as cost and availability of resources. Most of the time, guidelines are largely in agreement with each other, but we try to point out the differences or provide summaries of specific guidelines when they differ so that users in different areas can find the information that is most relevant for them. Another point worth noting is that it is not uncommon for there to be a Canadian guideline that addresses something not covered by a US guideline. And because we monitor the Canadian guideline groups, we can provide evidence-based recommendations on more subjects than if we only followed US guidelines. I think many other point-of-care tools have a distinctly US-centric orientation and the information reflects a perspective of how someone might practice in the US, which does not always apply in other settings.

"Most of the time, guidelines are largely in agreement with each other, but we try to point out the differences or provide summaries of specific guidelines when they differ so that users in different areas can find the information that is most relevant for them."

E.L.: DynaMed is a truly international resource, but as you might imagine, the Canadian perspective is unique from the point-of-view that it’s providing socialized medicine―which is more resource-conscious than other jurisdictions by necessity. The medicolegal climate and risk tolerance as well as access issues are unique as well. Inclusion of Canadian guidelines, especially those that are at low-risk of bias from commercial or professional conflict of interest, is very valuable. It provides Canadian users with that unique perspective, which is often quite different in a number of domains of medicine. Screening for cancer, for example, is one such area where Canadian guidance tends to be more tempered.

We all know physicians are busy. We all want the quickest information possible and as a result, we sometimes turn to “Dr. Google”. What are the downfalls to this, and what do you propose as a better solution?

E.L.: I guess the main issue is the signal-to-noise ratio. Dr. Google may be OK when looking up a quick item like a medication dose, but otherwise one runs the risk of falling upon content that is either out of date or influenced by bias―be it that of the author of that website’s content or some other external influence.  DynaMed’s process is very rigorous and relies only on the highest standards of medical literature, emphasizing when possible, evidence that is of high certainty (as opposed to speculative) and only highlights guidelines that adhere to current standards for trustworthiness. Even when the evidence has limitations, that information is readily apparent in the content.

"DynaMed’s process is very rigorous and relies only on the highest standards of medical literature, emphasizing when possible, evidence that is of high certainty (as opposed to speculative) and only highlights guidelines that adhere to current standards for trustworthiness."

A.E.: I find Google to be useful for discrete bits of facts. If you want to know the definition of a term or a 2-3 line description of what a certain disease is, Google is very fast and usually pretty accurate. Where one runs into trouble is when trying to get information about testing to do or help with establishing a treatment plan. In those situations, Google can be much slower than a well-curated database.

  1. Google’s relevancy rankings often do not necessarily present things in chronological order.
  2. When you go to read something, you don’t often know if it’s the most current information or not.
  3. Finally, even with current information, the quality of the data behind it is something that is important to know and is often not obvious in many resources.

I do not think it is a question of “what is a better alternative to Google?,” so much as it is “when do I use Google?” and “when is something else a better choice?”. Google is great for memory prompts and learning quick facts. But if I am trying to make a clinical decision, I want to use something that has been written by and for clinicians.

"If I am trying to make a clinical decision, I want to use something that has been written by and for clinicians."

So we can agree that Google serves a purpose, but point-of-care tools are probably the better resource for evidence-based clinical decisions. What enhancements or content is your team working on (recent past, present or future) to make DynaMed Plus the tool physicians reach for consistently, even when they’re on the go?

A.E.: The 2 key questions most clinicians look up when taking care of patients are: “what is going on?” and “what do I do?”. DynaMed tries to provide answers that the user can access very quickly in the form of overviews, with detailed supporting evidence available to those interested in a deeper dive. The “overview and recommendations” section gives a quick summary that is designed to address the most common questions about the topic. Within the body of the content, we have overviews for testing and for treatment that are again designed to give users quick answers. The combination of quick answers and ready access to robust supporting information is what makes DynaMed Plus such a useful clinical tool.

“The combination of quick answers and ready access to robust supporting information is what makes DynaMed Plus such a useful clinical tool.”

E.L.: DynaMed adheres to the principles espoused in the Institute of Medicine Report about “Knowing what works in health care”.  Systematic reviews, such as those found in Cochrane, are a key element of the guidance that is synthesized and summarized for DynaMed users. This is more reliable than a literature-based approach that might involve the author of a particular resource cherry-picking studies that support their view or how they’ve always practiced.

Do you have any “super user” tips for physicians who might already be using the tool but want to become more proficient? Are there any features they might not already know about?

A.E.: I think the tip I would give is that DynaMed is not designed to be read in a textbook fashion. It is designed for users to go in, find information, be done. As such, the features I use the most are the overviews (which have links for additional information within the topic), the left navigation bar which allows me to go directly to the relevant sections, and the “search within topic” tool for when I am looking for a specific term. Choosing which tool will help me find information the fastest will vary from one subject to another, and learning to be flexible in this way can really speed things up.

Figure 3: Search within topic in left navigation bar

E.L.:  I think the neatest thing developed in DynaMed is the “option grid”―which is a shared decision-making tool ideal for use to clinical decisions that are sensitive to patient values and preferences―i.e. a large number in an era where most recommendations are conditional (as opposed to strong or standards of care). The “patient information” section as well as the decision support tools are up and coming too. Of course, some of the most unique developments are related to integration with the electronic health record (EHR)―so that the relevant chapter is at the clinician’s finger tips when working within a given order set, for example.

Figure 4: The options grid
Figure 5: Patient information section

Lastly, what does the future of point-of-care tools like for each of you? I know it’s difficult to predict, but how far do you think they can go in the next 5 years?

E.L.:  Following up on the EHR point I raised above, I think we can readily envision the day where through artificial intelligence and machine learning, we can imagine that DynaMed-linked products can gather patient information and deliver contextually-specific information for clinical or even shared decision-making using “options grid”.  More and more of my patients are coming to the ED with their iPads and smartphones.  If resources were provided, they could become more informed and knowledgeable partners in the clinical care process.

“More and more of my patients are coming to the ED with their iPads and smartphones.  If resources were provided, they could become more informed and knowledgeable partners in the clinical care process.”

A.E.: I think that there will be a transition from generic information (that is meant to apply to broad classes of people) to much more patient-specific information to inform decision-making. I think that there will be features that will allow the input of comorbidities and demographic factors into search tools and return narrowly tailored information when available.


The views and opinions expressed in this article are those of the authors.  Please keep in mind the views of other authors do not necessarily reflect the views of the Canadian Medical Association or Joule. 

This interview was produced by Joule in partnership with EBSCO Health, the creators of DynaMed Plus®. Special thanks to Drs. Alan Ehrlich and Eddy Lang for sharing their expertise with us.

CMA members have access to DynaMed Plus included in the cost of their membership―a tool valued at $395 a year. Get started.


About Dr. Alan Ehrlich

Dr. Alan Ehrlich is the Executive Editor at DynaMed and an Associate Professor of Family Medicine and Community Health at the University of Massachusetts Medical School in Worcester.

 

About Dr. Eddy Lang

Dr. Eddy Lang is the Academic and Clinical Department Head and an Associate Professor in the Department of Emergency Medicine, at the Cumming School of Medicine, University of Calgary as well as a Recommendations Editor for DynaMed.

 

About EBSCO Health and DynaMed Plus®

Brian S. Alper, MD, MSPH, FAAFP created DynaMed in 1995 with a mission of providing the most useful information to healthcare professionals at the point-of-care.

In 2005, EBSCO Health acquired DynaMed. EBSCO Health’s experience in providing clinical decision support solutions, healthcare business intelligence, medical journals, medical e-books and medical reference information to hospitals and healthcare organizations worldwide proved a great match.

Today, the editorial leadership team has been expanded to include Deputy Editors across a wide range of specialties including infectious diseases, pediatrics, cardiology, internal medicine, neurology, critical care and many more. DynaMed was rebuilt from the ground up with new content, new platform, new mobile technology and new features. The new product, called DynaMed Plus, was launched in 2014. Now, thousands of healthcare organizations choose DynaMed Plus.


1 Allen D, Harkins KJ. Too much guidance? Lancet 2005 May 21-27;265(9473):1768.