33 Charts

UpToDate - The Information Prescription

UpToDate, arguably the most trusted information brand in medicine, is now in the patient information game with UpToDate for Patients.  I ran into deputy editor Alison Hoppin (a pediatric gastroenterologist) at the American Academy of Pediatrics last week and she gave me a test drive.  My bags are barely unpacked and I’m already using it in my practice.

I mean, what a concept.  Draw content from some of the best minds in medicine, add skilled editorial input, and package it in an approachable format without the glitz.  And unlike many supermarket health sites, UpToDate does not discriminate against the pediatric population.  You’ll find many diseases and conditions covered equally well for children and adults (see celiac disease in children).

And I love this:  UpToDate even offers information prescription pads for doctors.  Beyond simply reminding patients where to go, this makes the point that it’s a doctor’s responsibility to help patients initiate navigation in the online space (what I like to call preemptive online health literacy).

This icon sequence on the patient entry page gives some hint to where UpToDate sees this going. Reference step 3: some patients will want the full nine yards and pay for physician-level information.  And why not, really?

If UpToDate can expand its content and leverage its rock solid name with doctors, look for them to establish a powerful foothold with patients in the medical infosphere.

8 Ways Physicians Can Use Evernote

When I was a medical student I carried around a little black notebook.  It held my lists of differential diagnoses, workups, and other key clinical pearls.  In the middle of clinic when I needed to know the workup for rickets I had it right at my fingertips.  I had dozens of lists and differentials, many of which saved me on rounds or during busy ICU shifts.

I still keep lists and cheat sheets.  But now I keep them on Evernote.  Evernote is an application that allows the digital capture of notes, images, PDFs, etc in one place.  The iPhone app is phenomenal and syncs with Evernote on my Mac (or PC).

Here are 8 ways I use Evernote to make my medical life simpler:

1.  Workups.  Can’t remember the workup of a baby with cholestasis or the latest evaluation for autoimmune hepatitis?  I do liver for a living and I sometimes can’t keep it all straight.  An Evernote list is perfect place for differentials.  And the lists are right on my phone – if I catch wind of something new during a seminar or lecture, I can update my list on the spot.  I encourage students and residents at Baylor College of Medicine to record their differentials and workups as they learn them.  What you hear on rounds today you won’t remember in two months.

2.  Names.  I just can’t seem to remember the names of all those wonderful ladies in medical records.  So I keep them on a list that I peek at just at before going to complete charts.  Disingenuous?  No.  Smart, yes. 

3.  Capture papers, PDFs and peripheral stuff.  Evernote is a great place to keep journal articles, images and other stuff for reference.  And all of it is retrievable on your iPhone or Blackberry.  For a great screencast detailing how to use Evernote this way, check out this great video by fourth year medical student Ryan MacDonald.

4.  Patient plans.  If you keep up with 33 Charts you’ll know that I use dry erase boards in my office to help patients understand differentials and plans.  Many times I snap a picture into Evernote and refer to it at the end of the day when completing charts (no patient information attached, Evernote isn't HIPAA compliant).

5.  Special dosing.  Sure we’ve got Epocrates and other great apps for medications, but there are still situations where you need to remember special dosing protocols.  For example, 2-3 times a year I use methotrexate for crohns disease.  I keep my recommended dosing schedule and monitoring protocol right in Evernote.  This week I had to start subcutaneous vitamin B12 on a boy with short gut syndrome.  I recorded the protocol that our PharmD and RD uncovered.  Next time I’ll have it at my fingertips. 

6.  Grab that poster.  At meetings I have used Evernote to capture pieces of poster abstracts.  Conclusions, graphs, or any other type of content you want to take with you.  And your photographed words even become searchable on your iPhone.

7.  Capture ideas.  Inspiration strikes at strange times.  Book ideas, blog concepts, potential articles come and go in my head.  A lot of my clinical ideas come when I’m ... in clinic.  I’ve gotta get ‘em down before they disappear.

8.  Stop wandering in parking lots.  I travel a lot, Houston has a big airport garage, and I’m getting older.  This is bad combination.  So I never leave the garage without noting my garage, level and zone.  I can even snap a picture of the location or ask Evernote to retrieve notes based on my location.

And I’ve only scratched the surface.  If you have any great medical uses for Evernote, let me know in the comments below.

Other links of interest

• 14 Practical Ways to Use Evernote - Pithy summary by Guy Kawasaki
• Noteworthy Blog - Evernote's blog with lots of tips and links
• Twenty Ways Surgeons Should Use Evernote - This one speaks for itself

Take a Peek to the Beach

I’ve never done this before.  The folks over at Typepad asked if I’d like to monkey around with a Peek device.  I said yes.  They mailed me one.  No money ever changed hands.  I took it on vacation and here  we are. 

I will remind you, however, that I’m no Walt Mossberg.

For the uninformed, the Peek is a bare bones email/text only device working to position itself among a growing population of smart devices.  The Peek Pronto allows up to 5 email accounts, unlimited email/text, ability to view PDFs and images as well as exchange support.

I activated my Peek with before heading out for a week at Hilton Head, SC.  Despite the fact that I rigged up my Peek cross-eyed at 11:30 pm after packing, total time to setup was a flat 2-3 minutes.  And after an overnight charge we were good to go.  I did leave the manual at home which as it turns out wasn’t an issue.  As my IT guy might say, ‘this thing’s so easy even a doctor can figure it out.’

The Peek Pronto served as my wife’s sole access to email during our week away.  She uses a standard flip phone so the novelty of portable email was something to see.  Otherwise, it performed really well and was easy for us to understand and put to immediate use.  Battery time was outstanding despite a bright, crisp screen.  And interestingly the email reception on the Peek Pronto far exceeded what I was able to achieve with my iPhone on Hilton Head (notoriously poor cell coverage).

With the recent shake up in the smart phone market the price of the Peek Pronto has dropped to a mind blowing $59.  This facile entry point with $20 a month buys you unlimited email and text.  Not a bad way to stay connected on the cheap.

The $59 question is this:  Are the desperate-to-be-connected going to quibble about 50 bucks and move to an iPhone or equivalent smart phone?  I don’t know.  I suspect that this device will find a home not with the desperate-to-be-connected but rather with the frugally minded and those who don’t need handheld web access. 

As the market never lies, only time will tell. 

For more insight, check out this Wall Street Journal piece, Peek Takes on Gadget Market

Preemptive Online Health Literacy

I recently discussed endoscopic biopsy results with a patient’s mother.  Her child had inflammation in the upper intestinal tract with cells called eosinophils.  As I began to explain the basics of tummy irritation and the significance of the eosinophils in her daughter’s duodenum she cut me off, “Actually doctor, you don’t need to go into too much detail, just spell ‘eosinophil’ for me if you would.”

As it turns out mom was more interested in getting to Google than listening to how I think her daughter’s biopsy results related to her problem.

I wasn’t put off or irritated.  There was once a time when I would have been.  I did feel compelled, however, to help her understand what she would find online when searching for eosinophils and how that information may or may not be applicable in this case.  

Having faced this scenario hundreds of times I know what parents are going to find when they search for eosinophils, how they will confuse information on adult and pediatric disease, what they’ll be concerned about and what test they’ll ask me to run on the first follow-up visit in the office.  So I address it all up front.  Call it preemptive online health literacy.  Time consuming you say?  Not as time consuming as letting patients wander aimlessly.

The internet isn’t going anywhere.  If anything, the web's capacity to support patients will only improve.  As medical professionals we have to be competitive with the infosphere.  And the only way to remain competitive is to offer something that isn’t readily available.  Our greatest strength comes in understanding individual patients, their problems, their fears and their agenda.  Google fails on this task.  With the right relationship and a thorough understanding of the human reaction to illness, we can coach, direct, and leverage the power of the online information.  This is how we stay relevant.