what internet site do doctors go to for information
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Abstract
Groundwork: The complexity of modern practice requires health professionals to be active information-seekers.
Objective: Our aim was to review the quality and progress of point-of-care information summaries—Spider web-based medical compendia that are specifically designed to deliver pre-digested, rapidly accessible, comprehensive, and periodically updated information to health care providers. We aimed to evaluate production claims of being bear witness-based.
Methods: We updated our previous evaluations past searching Medline, Google, librarian clan websites, and conference proceedings from Baronial 2012 to Dec 2014. Nosotros included Web-based, regularly updated betoken-of-care information summaries with claims of beingness evidence-based. Nosotros extracted information on the general characteristics and content presentation of products, and we quantitatively assessed their breadth of disease coverage, editorial quality, and bear witness-based methodology. Nosotros assessed potential relationships between these dimensions and compared them with our 2008 assessment.
Results: We screened 58 products; 26 met our inclusion criteria. Nigh a quarter (half-dozen/26, 23%) were newly identified in 2014. We accessed and analyzed 23 products for content presentation and quantitative dimensions. Most summaries were developed by major publishers in the Us and the Great britain; no products derived from low- and middle-income countries. The main target audience remained physicians, although nurses and physiotherapists were increasingly represented. Best Practise, Dynamed, and UptoDate scored the highest across all dimensions. The bulk of products did non excel across all dimensions: we found only a moderate positive correlation between editorial quality and evidence-based methodology (r=.41, P=.0496). However, all dimensions improved from 2008: editorial quality (P=.01), show-based methodology (P=.015), and volume of diseases and medical conditions (P<.001).
Conclusions: Medical and scientific publishers are investing substantial resources towards the evolution and maintenance of point-of-intendance summaries. The number of these products has increased since 2008 forth with their quality. Best Practice, Dynamed, and UptoDate scored the highest across all dimensions, while others that were marketed as evidence-based were less reliable. Individuals and institutions should regularly appraise the value of signal-of-care summaries equally their quality changes apace over time.
doi:10.2196/jmir.5234
Keywords
Introduction
Pressed for time and obliged to navigate always-expanding medical literature, doctors are increasingly relying on online information tools to accelerate the search process without compromising the reliability and quality of data retrieved. Point-of-care information summaries offer predigested syntheses of medical research intended to be used when the patient and physician interact (ie, point-of-care) []. Web-based betoken-of-care summaries provide convenient interfaces that may ameliorate the retrieval, synthesis, arrangement, and awarding of evidence-based content in clinical practice [,].
The medical information technology marketplace parallels the efforts past national health systems to streamline clinical workflow and align clinicians' behavior with all-time practice strategies. Signal-of-care summaries play a central role: they increasingly form the knowledge ground of complex information systems, such every bit computerized doc order entry and estimator decision support systems [-]. In the United States, the Health Information Technology for Economic and Clinical Health (HITECH) Deed requires clinicians and hospitals to integrate electronic health records (EHRs) with clinical decision support rules relevant to a specialty or to high-priority hospital weather, such as drugs and diagnostic test ordering []. In Europe, the integration of point-of-care summaries into the workflow of the prescribers is under scrutiny in several countries [-].
Every bit signal-of-care information summaries gain ground in the culture of medical practice as stand up-alone products or integrated with other systems, their validity must be assessed against marketing claims that they are bear witness-based. This review examines the quality of Web-based bespeak-of-care information summaries and their development and progress since 2008.
Methods
Inclusion and Exclusion Criteria
As this is an update of analyses washed in 2008 [] and 2012 [], detailed methods and operational definitions can exist plant in the original publication []. Briefly, we defined bespeak-of-intendance data summaries as "Spider web-based medical compendia specifically designed to deliver predigested, apace attainable, comprehensive, periodically updated, and evidence-based information (and possibly too guidance) to clinicians." To be included in this review, a product had to be an online-delivered tertiary publication (summary) that is regularly updated, claims to provide show-based data to physicians and other professionals, and is intended for utilise at the bedside. We considered summaries, regardless of their content evolution status, number of years on the market, clinical focus or specialty, type of access, or charging agreements. We excluded other online information resources such as guideline databases, meta-lists and search engines, literature surveillance alerting systems, online books, and journal manufactures (ie, primary and secondary literature). Our analysis was limited to products in the English language.
Search Strategy
To place the point-of-care information summaries, we re-examined the eligibility of all products that were included or excluded in the 2008 and 2012 analyses. To discover new summaries, we searched Medline from Baronial 2012 to December 2014 with the following terms: (("Evidence-Based Medicine"[Mesh]) AND ("Information Storage and Retrieval"[Mesh])) AND (("Online Systems"[Mesh]) OR ("Bespeak-of-Care Systems"[Mesh])). We scanned the references of the papers retrieved and used the Google search engine to place additional products that may not accept been reported in the medical literature. We explored various publisher and librarian association websites (ie, Quango of Scientific discipline Editors, the World Clan of Medical Editors, the European Clan for Health Data and Libraries, and the American Medical Information science Clan) [-], and the 2014 conference proceedings from the Medical Library Association Meeting and Exhibition [].
Identification of Point-of-Intendance Information Summaries
One reviewer examined the search results, screened the titles and abstracts of papers identified through Medline, and evaluated the eligibility of products integrating additional information found on production websites. If at that place was dubiousness virtually the inclusion of a product, all authors discussed the eligibility until a consensus was reached. We recorded the reasons for exclusion.
Data Extraction and Analysis
1 reviewer extracted information on the general features of each point-of-intendance information summary. Products that could not be accessed (ie, no subscription available at our institution, no free-trial selection, and no response from product representatives to our emails requesting access) were excluded. One reviewer collected data on the general characteristics of products and their content presentation for qualitative (descriptive) evaluation, along with data about the editorial quality, evidence-based methodology, and content volume (breadth of diseases and medical weather covered) for empirical quantitative analysis. A second reviewer checked the extractions.
Qualitative Evaluation
For each summary included, we collected the following general details: country of evolution, year of release, vendor or publisher, marketing claims, format (eg, tablets, mobile devices), admission and subscription options, annual costs, and targeted audience. Since the 2012 analysis, we have introduced an additional component: ability to be integrated into an EHR system. This entails the capacity to access information from the bespeak-of-care summary directly through the EHR interface. For example, when a doctor clicks on a status written in the patient record, the doc is directed to a new screen detailing disease information and treatment options. A signal-of-intendance summary search tool may be additionally available on the EHR interface to make complimentary-text and International Nomenclature of Diseases (ICD)-10 code searches.
Content presentation was analyzed in summaries that we accessed. We examined the different outputs (eg, key point summary, paragraphs, question and answers, volume chapter-like summary, clinical pathway, clinical scenario), use of formal ontology, flexibility, and reporting of references (with or without full general or specific citations). We likewise assessed products' adoption of an intent to recommend, utilize of a formal strength of recommendation arrangement, likewise every bit the availability of standing medical pedagogy programs or credits, other teaching materials (eg, lessons on statistical analysis or evidence-based methodology), and patient handouts.
Quantitative Analysis
Two reviewers extracted information nearly three fundamental dimensions: quality of the editorial process, quality of the show-based approach to content development (ie, evidence-based methodology), and volume or breadth of the medical weather condition covered. We described products quantitatively using three split scores that covered components relevant to each dimension. Disagreements were resolved by discussion between the reviewers. A 3rd writer was consulted for any unsolved discordances. All Web pages providing useful data were saved and stored in an electronic archive. When information well-nigh a particular component (eg, commercial support or critical appraisal) was unclear or could not exist found, we contacted publishers by email requesting boosted information and description of contents. All emails were stored in an electronic archive.
Editorial Quality
Nosotros adopted the following indicators of transparency to evaluate the methodological quality of the editorial process: authorship (reporting of authors for each summary), reviewing (implementation of a formal, structured peer-review procedure), updating (whether or not summaries had been revised or updated in the previous 2 years), conflicts of interest (disclosure of contributing authors' conflict of interest), and commercial support for content development. For this final component, we assigned three points if commercial support was not accustomed, one signal if commercial support was accustomed and reported, and no points if the product programmer did not present sufficient information for us to make a judgement. For the remaining items, we assigned 3 points if the component was judged as "adequate," one point if "unclear," and none if "not acceptable" or "not reported." We arbitrarily decided to award three points instead of two for the adequate fulfillment of a criteria in gild to give more weight to transparent and accountable reporting, and increment variability within the sample.
In the 2008 and 2012 reviews, we assessed the authorship, authors' conflicts of interest, and updating of products based on the editorial policy statements. If the information provided was insufficient to make an accurate evaluation, we referred to a nonrandom choice of sections (often referred equally topics) to assess the dimensions. In the attempt to minimize bias between reporting and implementation in the 2014 analysis, we evaluated these dimensions through a random sample of topics. We randomly selected ten blocks or categories of diseases from ICD-x []. If any product did not cover one of the medical conditions identified in a block, we randomly selected some other block from ICD-x. In each topic, we checked the reporting of authors too every bit any potential conflict of interest. For updating, topics were considered up-to-date if they had been reviewed or revised within the terminal ii years (Jan 2013 to January 2015). The two-year time frame was determined based on the average time to changes in evidence that are sufficiently important to require the updating of systematic reviews []. Products with eight or more topics updated in the final 2 years were assigned 3 points towards the total editorial quality score. Products with three or less topics updated within that period were assigned no points. Other products with iv to vii updated topics were assigned 1 point as well as those that did not consistently provide dates on the articles.
Evidence-Based Methodology
The following components were used to evaluate the forcefulness of the evidence-based methodology for content development: implementation of a literature search or surveillance strategy to place current data, cumulative versus discretionary arroyo (prioritization of systematic reviews over other evidence sources), disquisitional appraisal, formal grading of show, and citation of expert opinions (separation of skilful opinions from other evidence sources in summaries). Three points were assigned if the component was judged "acceptable," one if considered "unclear," and none if "not adequate" or "non reported."
Book (Breadth of Diseases Covered)
Equally it was not feasible to count the total number of diseases and medical conditions covered in each product, we estimated the comprehensiveness of disease coverage by verifying the presence or absence of a random sample of diseases from the ICD-10 []. We randomly selected iv chapters: Chapter IV—Endocrine, nutritional and metabolic diseases, Seven—Diseases of the eye and adnexa, XII—Diseases of the skin and subcutaneous tissue, and XV—Pregnancy, childbirth and the puerperium. These chapters comprised a total of 35 blocks or categories of diseases or medical conditions. If a point-of-care information summary discussed at to the lowest degree 1 disease specified within a block, the production was assigned i signal towards a maximum of 35 full points for volume. We and then converted the volume scores into percentages, where 35 points correspond to 100% coverage.
summarizes in a menstruum diagram the methods used to evaluate products.
Analysis
Volume and quality indicator scores are presented with medians and interquartile ranges (IQR). Point-of-care information summaries were ranked on the basis of (1) editorial quality, (2) the employ of an evidence-based approach, and (3) the book of diseases covered based on a random sample of ICD-ten chapters. Correlations between these 3 dimensions were assessed by Spearman rank correlation coefficients and their corresponding P values. Changes in the strength of the products from 2008-2014 were assessed using the matched pairs Wilcoxon signed-rank test. For hypothesis testing, a probability of <.05 was considered statistically significant. All statistical tests were ii-sided. Stata software was used for statistical analyses.
Results
The search strategy identified 58 products for potential inclusion. Later on screening, 26 fulfilled our inclusion criteria. Sixteen of these were previously included in the 2008 and 2012 reviews (5 Minute Consult, BestBets, Clin-eGuide, Dynamed, EBM Guidelines, Essential Bear witness Topics, eTG Consummate, GP Notebook, Map of Medicine, Micromedex, Mosby'southward Nursing Consult, Nursing Reference Center, PEPID, Rehabilitation Reference Center, UpToDate, and Zynx Evidence). Iv products inverse into a new product since 2012 (ACP Smart Medicine formerly ACP Pier, Best Do formerly Clinical Evidence, Clinical Key formerly Start Consult, Medscape Drug and Diseases Reference formerly Emedicine). Six products were newly identified in this review (Clinical Access, Cochrane Clinical Answers, Decision Back up in Medicine, Dainty Pathways, PEMSoft, and Prodigy). Prodigy, which is connected with Clinical Knowledge Summaries (CKS), was considered a new production since CKS was discontinued for some time and only in 2012 was restarted. shows the flow diagram for the pick of indicate-of-care information summaries in the review.
In order to access the 26 products, we registered for gratis-trial access online whenever available or contacted the publishers directly requesting temporary admission to perform the evaluation. Nosotros did not receive a response from the publishers of three products (Clin-eGuide, Mosby's Nursing Consult, and Zynx Show), which were prevented from further evaluation. A full of 23 products were included in the content presentation and quantitative assay.
Qualitative Evaluation
General features are summarized in . Most of the 26 products were adult by major publishers in the United states (n=12) and United Kingdom (n=8), while others came from the Netherlands (north=4), Finland (due north=1), and Australia (n=ane). A minority was open access (19%), while most were fee-based (81%) with a median private subscription price of €244.4 (US$265, £169.52). Regarding their electronic compatibility, over a quarter (7/26, 27%) of products were Web-based only, as others could besides be opened on mobile devices. Nigh products targeted a general audience of health professionals (18/26, 70%), but some were advertised for specific groups such as medical specialists (1/26, 4%), general practitioners (2/26, 8%), nurses (2/26, 8%), emergency medicine doctors (one/26, 4%), pediatricians (ane/26, 4%), and rehabilitation professionals (1/26, 4%). Sixteen products out of 26 (62%) could be integrated into EHRs.
presents details of the summary content presentation of the 23 products we could fully evaluate. Products displayed their content in a multifariousness of formats: cardinal point summary, questions and answers, volume chapter-like summaries, and clinical pathways (menstruum charts). Almost had a formal ontology for organizing diseases and medical conditions (xx/23, 87%) likewise as flexible navigation of topic contents (nineteen/23, 83%). Although many products adopted an intent to recommend arroyo (17/23, 73%), under a 3rd (7/23, 30%) used a formal forcefulness of recommendation system: Grades of Recommendation, Assessment, Development and Evaluation (GRADE) arroyo [], the Strength of Recommendation taxonomy (SORT) by the American Academy of Family Physicians [], or individual systems developed for the product. Simply under a one-half (11/23, 48%) of products awarded standing medical pedagogy credits for searches or featured other programs for standing medical education. Patient education materials and handouts were bachelor in nearly a third (7/23, 30%) of products, and but a few (iv/23, 17%) offered additional educational materials for clinicians such as evidence-based medicine and critical appraisal methodology, lessons on cultural competencies, laboratory manuals, and practice resource.
Quantitative Assay
shows the rank of products based on volume. Disease coverage varied widely: the median volume or coverage of medical weather condition was 94% (IQR, 66-100%). The nigh comprehensive products providing at least one status per disease category in the four ICD-10 chapters were 5 Minute Consult, Best Practice, Clinical Admission, Dynamed, GP Notebook, and UpToDate.
Editorial quality and evidence-based methodology are summarized in and ; the median scores were 12 (IQR 6-13) and 11 (IQR 4-15), respectively, on a 15-point scale. Five products (ACP Smart Medicine, BMJ Best Practice, Dynamed, Essential Evidence Topics, and UpToDate) received the maximum score for editorial quality. Half-dozen (ACP Smart Medicine, BestBets, BMJ Best Practice, Dynamed, EBM Guidelines, and UpToDate) received the maximum score for prove-based methodology.
The ranking of point-of-care information summaries based on their strength of volume, editorial quality, and bear witness-based methodology is shown in (total information reported in -). Best Practice, Dynamed, and UpToDate scored in the highest quartile across all three dimensions. There was a moderate positive correlation between the editorial quality and evidence-based methodology of products (r=.41, P=.0496). No correlations were found between editorial quality and volume (r=.10, P=.64), or between prove-based methodology and book (r=.06, P=.80).
Compared to the 2008 evaluation, at that place were significant improvements in all three dimensions: editorial quality (P=.01), evidence-based methodology (P=.015), and volume (P<.001). shows the evolution of the products in the 2014 assessment that were previously evaluated in 2008.
Discussion
Principal Findings
To evaluate products' claims to be prove-based, we adopted editorial policy, content quality, and coverage of medical noesis equally the central indicators of high-quality point-of-care information summaries. In line with the 2008 and 2012 analyses, the purpose of our study was not to pinpoint the "winning" and "losing" products but to assess the maturity of these tools for clinical decision making and encourage transparent reporting of editorial and content development policies by publishers. We further sought to guide readers in the pick of products for individual or institutional use. Since 2008, there have been improvements in the general features of indicate-of-care information summaries and the descriptions of their editorial approaches, though suboptimal products are nonetheless on the market [].
Several limitations to our study must be noted, including use of editorial policy statements to decide the implementation of a formal and structured peer-review process and the credence of commercial support for content evolution. We acknowledge that there may take been discrepancies between the reporting and actual implementation of editorial policies. Moreover, although we included quality dimensions informed by bear witness in our report, our criteria for assessment may be perceived as capricious; users of a given point-of-care summary may take unlike views or experience. Regardless of potential differences in opinions, i observation remains articulate: publishers have invested notable energy and resources to enhance their quality standards in a limited time. Product maturity and the increasing value of reliable information in medical club may sustain the ascension popularity of point-of-care summaries amid health professionals.
A item challenge within our study involved the defining of the intervention and execution of the search strategy to identify relevant interventions for inclusion. Since our first evaluation in 2008, there continues to be a discrepancy in the terminology adopted to depict what nosotros identify as "point of care information summaries": Web-based medical compendia that are specifically designed to deliver predigested, rapidly accessible, comprehensive, and periodically updated information to health intendance providers. These products have been additionally referred to as "prove-based textbooks" [], "clinical point-of-care tools" [], navigators, and services []. While nosotros recognize that other terms might exist used, we have adopted point-of-care information summaries equally the preferred terminology, as it embraces several central content elements. Given the rising involvement and adoption of these tools, the development of a mutual term and definition will facilitate their assessment by researchers also as by hospitals and health intendance professionals in search of a compatible tool for apply. A common definition might likewise do good the PubMed MeSH vocabulary. In fact, the MeSH term "point-of-care systems" comprises a wide range of health intendance technologies outside of our intervention, such as laboratory and diagnostic instruments [].
The quality of most products is still moderate, which has too been indicated by the few additional surveys evaluating the quality of point-of-care data summaries [,-]. Clinicians should go familiar with the basic concepts that make an data production a credible source of scientific evidence. Wellness libraries and local knowledge brokers should endorse and give preference to summaries that are committed to policies to amend editorial and methodological rigor, disclose conflicts of interest [-], and ensure complete and accessible reporting of the content development procedure. Users should be skeptical nearly signal-of-care summaries that practice not transparently describe how information is constitute (search strategy), selected (cumulative or discretionary approach), evaluated (disquisitional appraisal), prioritized (grading of evidence and recommendations), and regularly updated (literature surveillance) to maintain their relevance to exercise. Publishers may be highly skilled in boosting clinical recommendations through propaganda and legally qualified to sell their products to doctors and hospitals. Moreover, the failure to disclose methods for product development is not in the best interests of the medical community, and might, in fact, depict the line between authoritative and fraudulent therapeutic data.
Point-of-care data summaries largely serve high-income countries. Notwithstanding, data on highly effective medicines and interventions are presumably more than valuable in low- and heart-income countries. At the same time, in an increasingly competitive market, publishers cannot brand the service "free for everyone" because this would affect their sustainability and might facilitate the opportunistic utilise of these resource. We encourage publishers to align the prices of their products to the purchasing power of a item country'due south physicians through tiered-pricing models and to distribute admission through networks active in low- and heart-income countries [,]. In addition to their affordability and access, the source of information is disquisitional to the strength and reliability of products.
Dynamed currently has links to over 17,000 guidelines, organized for high or depression- to middle-income countries []. While the consideration of ready-to-employ recommendations is a fundamental first step, more investments in tailoring information to local doctors and other health care providers are needed. For instance, information on medicines was never ranked on the footing of the WHO Model List of Essential Medicines, which selects treatments that offering a cure or effective illness direction in preference to those that offer only marginal benefit []. Doctors are increasingly interested in knowing potential incongruence between investing resources and desired health outcomes [,]. In this time of thrift, betoken-of-care summaries have to practise a better job because the social proven value of medicines.
Future Considerations
It is not piece of cake to predict what directions publishers should accept to further improve their services. We advise three approaches. First, as summary providers mature and their contents become broader and more complete (eg, information about medicines, recommendations, and guidelines), information must be re-filtered to meet personal practice needs. Users volition need to personalize the production, setting filters to isolate specific information (eg, local hospital guidelines) that is relevant to private clinical practice. This will prioritize information that tin can engender changes in health professional behavior [].
2nd, high-quality point-of-intendance summaries should exist integrated into computer decision support systems for EHRs. These reckoner systems may correspond the future of clinical decision making in which bear witness-based knowledge from indicate-of-intendance summaries is linked with patient information from EHRs to generate case-specific guidance messages through rule- or algorithm-based software [,]. Figurer decision support systems combined with EHRs might exist beneficial for the health care provided to patients, although it is difficult to demonstrate their association with benefits on outcomes such as mortality [].
Third, the potential integration of signal-of-care summaries into continuing medical education programs should be recognized []. Doubts that are raised during clinical consultation tin trigger point-of-care searches that provide wellness professionals with valuable information that tin can be straight implemented in the visit. Accreditation systems demand to recognize the role of indicate-of-care summaries equally an efficient provider of relevant knowledge.
Conclusion
The maturation of signal-of-care summaries tin can be seen as a virtuous circle []. Information technology started with an exogenous gene: technological innovation. As health professionals become increasingly familiar with the summaries, their adoption will become self-reinforcing. In a competitive marketplace, this will probably help lower product prices, leading to more than potential users. The last 20 years saw the success of PubMed, The Cochrane Library, and, more recently, WikiProject Medicine, which are now integral parts of medical practice. Publishers and developers of betoken-of-care summaries need to direct their considerable talents and resources to developing strategies to sustain affordable do and interventions to meliorate quality of practice. This change of focus can support their development as indispensable professional tools.
Acknowledgments
This work was supported by the Italian Ministry building of Health (GR-2009-1606736) and by Region of Lombardy (D.R.L. Nine/4340 26/10/2012). Funding sources had no role in writing this manuscript or the determination to submit it for publication. We would also like to thank Judith Baggott for editing.
Authors' Contributions
RB and LM conceived and designed the study. KK, MG-L, and RB collected the data. SB provided statistical expertise and analyzed the information. KK, MG-Fifty, and LM drafted the article. All authors contributed to the interpretation of the data, critically revised the commodity for important intellectual content, and approved the manuscript. LM is the guarantor of the article.
Conflicts of Interest
LM is employed past the IRCCS Galeazzi and Università degli Studi di Milano, which accept nonexclusive contracts with commercial publishers to develop or adapt betoken-of-intendance services to local or national settings. LM received remuneration for consultancy fourth dimension. LM is the PI of 2 randomized controlled trials testing the effectiveness of estimator conclusion support systems based on a point-of-care service (ie, EBM Guidelines) evaluated in this manuscript.
Abbreviations
| EHR: electronic health record |
| ICD-ten: International Nomenclature of Diseases, tenth Revision |
| IQR: interquartile ranges |
Edited past Grand Eysenbach; submitted 13.10.15; peer-reviewed past S Van de Velde, A Ketchum; comments to author 04.11.15; revised version received 19.11.xv; accepted 20.11.15; published 19.01.16
Copyright©Koren Hyogene Kwag, Marien González-Lorenzo, Rita Banzi, Stefanos Bonovas, Lorenzo Moja. Originally published in the Periodical of Medical Internet Research (http://www.jmir.org), 19.01.2016.
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Source: https://www.jmir.org/2016/1/e15/
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