Accuracy of PoC Resources to Answer Clinical Questions Ann McKibbon MLS PhD Associate Professor Clinical Epidemiology & Biostatistics McMaster University

POC Information Resources Tremendous need for them Already used heavily Traditionally thought of as being – Positive – Neutral Problems with content (itself or its application) Problems with use (system or user) We need to address the challenges – Complexities – Their possible dark side

Information Needs in Practice External information is vital in healthcare Numbers consistent over time, countries, disciplines, settings, training levels Clinic setting – Covell et al need/patient – Ramos et al need/patient Hospital setting – Osheroff et al /patient/day – Currie et al200311/hour with EMRs (range 1 – 25)

Clinicians use electronic resources during patient care time 89% of them believe that electronic systems improve care 75% of questions were answered

Problems with Information Finding Time Recognizing needs Complexities – Resources – Marketing/packaging Systems – Move to simpler ones Inability of resources to provide answers Trust of producers & systems Interpreting Time Recognizing needs Formulating questions Synthesizing evidence Coming up with the answer – Matching evidence with clinical situation and patient Application Trust of producers & systems

Seeking Information Most use external resources – People/peers – Electronic information resources – Non electronic resources Half of questions are pursued – 40% evidence found easily – 30% evidence found with difficulty – 30% evidence not found

Time to Find MEDLINE Use Times per Search 43 minutes in Oregon 24 minutes in Iowa 23 minutes in Hamilton Non MEDLINE times (e.g., PIER, UptoDate, CE, Google) range of 3 to 7 minutes Sackett and Straus: On wards, resources will not be used if search time is > 30 seconds

Complexities of Systems Size – MEDLINE 17,000,000 Version control – Cochrane reviews – Clinical practice guidelines Multiplicity of resources – Numbers and kinds Packaging of systems Data itself

Complexity of Systems Clinicians often use systems poorly: Scenario: Is PSA (prostate-specific antigen) a better biochemical predictor than alkaline phosphatase for detecting recurrent prostate cancer? Approach: OVID MEDLINE prostate cancer (18K citations) reads for 5 minutes quits provides answer

PackagingCochrane Reviews Whole content Cochrane Collaboration Database vendor (Wiley) PUBMED OVID – MEDLINE – EBMR Cochrane Library – EBMR Full Text – EBMR All InfoRetriever Google Scholar Partial content ACP Journal Club Evidence Based Medicine Evidence Based Nursing InfoPOEMs OVIDEBMR ACP J Club Clinical Evidence Google Evidence-Based Guidelines … Abstracts or full text? Free or pay?

Inability to Get Correct Answers From Peers Dutch study (Schaffsma) of 14 physicians Asked peers for answers to 12 questions 47% correct

Inability to Get Correct Answers From Peers Dutch study (Schaffsma) of 14 physicians Asked peers for answers to 12 questions 47% correct – If evidence provided 83% correct – If evidence not available 35% correct

Inability to Get Correct Answers From Electronic Information Resources Medical, NP students:45% right to 77% right Australian GPs:29% right to 50% right McKibbon study:39% right to 42% right

Inability to Get Correct Answers From Electronic Information Resources Medical, NP students:45% to 77% 12% right wrong Australian GPs:29% to 50% 7% right wrong McKibbon Study:39% to 42% 11% right wrong

Providing AnswersEKGs Electrocardiogram with computer interpretation 30 Internal Medicine residents (year 2 or 3) Accuracy Without e-interpretation of data48.9% With e-interpretation of data55.4%

Providing AnswersEKGs Electrocardiogram with computer interpretation 30 Internal Medicine Residents (year 2 or 3) Accuracy Without e-interpretation of data48.9% With e-interpretation of data55.4% – If e-interpretration correct68.1% – If e-interpretation wrong48.3%

Trust Producers of information trusted – WHO technical document Trust of technology – Social conformity – Less vigilance – Diffusion of responsibility – Belief in infallibility of technology

Summary Good systems exist although… …systems that provide – right answer – to right question – at the right time – in the right format – with little or no effort May not be here yet But we are getting closer…