NEFROLOGIA. Vol. XVIII. Supl. 6. 1998 Up-To-Date in Nephrology. A way out of the textbook and MEDLINE Morass M. D. Burton D. Rose Associate Professor of Medicine. Harvard Medical School. A 43 years-old man has asymptomatic proteinuria and a renal biopsy reveals focal glomerulosclerosis. How should he be treated? On another day, a 50 year-old woman on maintenance dialysis has persistent anemia despite erythropoietin therapy and has equivocal serum iron studies. What is the role for iron replacement? Questions such as there arise every day in clinical practice. Some are common problems while others may relate to diseases you see infrequently. A study published in 1985 monitored the practices of internists and assessed both the frequency with which questions occurred to which the physician did not know the answer, and how often and how the physician attempted to get the necessary information 1. The following observations were noted which are intuitive to any of us who regularly see patients: · 66 percent of patient visits generated a question to which the physician did not know the answer. · For subspecialists, 70 percent of questions were outside the physician's specialty. · Only 30 percent of questions were answered, most often by asking another physician; textbooks and journals are used to provide only 10 percent of answers. Most importantly, it was estimated that if the answers to all questions were readily available, as many as four management decisions might be changed each half-day of practice. Another study performed a similar evaluation on the medical service of a teaching hospital 2. Twentyfour house officers and students were evaluated over a 17-hour period, including rounds with the attending physician. During the period, 337 questions concerning patient care were asked, approximately one-half of which could be found in the chart, and one-quarter of which required synthesis of patient information and medical knowledge. The remaining 23 percent (77 questions) could not be answered by any of the physicians and required going to a textbook or performing a literature search. However, getting information remains a major problem. Textbooks are one year or more out of date when first published, the information you desire may not be included, and specific recommendations are usually not made. Literature searches are time-con10 suming and some expertise is required. In one report, for example, the average literature search took 25 minutes to complete (this includes the time spent reading and trying to interpret the multiple abstracts that are found) but the search efficiency was much less than that of a trained librarian with 45 percent of relevant articles being missed 3. Literature searches are easy and intuitive if one wants to know if two conditions are related (eg. eythromycin and the long QT syndrome) but are much more difficult if trying to get answers the diagnostic or therapeutic questions such as athose described above. Thus, most physicians prefer informal or formal consultation with a colleague with expertise in the desired area 1. Recognizing these difficulties, a review published in 1991 listed the characteristics of an ideal knowledge system 4: · The system must be comprehensive. · The information must be current, accurate and verifiable (well-referenced). · The information must be easy to access with an indexing system that includes common synonyms and abbreviations. · Updates should be issued regularly. · The system must be easily accessible where doctors see patients. If was noted that few systems met even one of these criteria. It should also be emphasized that an ideal knowledge system would not be used solely to answer specific questions as they arose. If the system were sufficiently comprehensive and easy to use and understand, it could also be used to review areas in which the physician was curious. A nephrologist, for example, might want to review the current thinking and genetic defect in Bartter's syndrome. Use in this manner would restore the intellectual joy and challenge of medicine to practitioners who are now too busy to scan more than one or two journals on a regular basis. WHAT IS UPTODATE UpToDate is a CD-ROM bases program that provides the physician with almost immediate access to exactly the information he or she wants. Develop- UPTODATE IN NEPHROLOGY. A WAY OUT OF THE TEXTBOOK AND MEDLINE MORASS ment began in 1989: the nephrology and hypertension section became available in late 1992; cardiology, pulmonary-critical care, and endocrinologydiabetes in late 1996; and rheumatology in the second half of 1997. Gastroenterology-hepatology and primary care will be available in the second half of 1998; and the remaining subspecialties (hematology, oncology and neurology) should be completed in 1999. All of this information is on the same CD-ROM. Each user gets a new CD-ROM every four months that completely replaces the previous CD-ROM. The basic principle of UpToDate is that there are a finite number of commonly asked questions that arise in the practice of internal medicine. We estimate that there are approximately 400 to 600 in each of the different subspecialties and that, with overlap among subspecialties, there may be approximately 5000 questions in all of internal medicine and primary care. Given the premise, we can identify the questions and recruit a faculty of experts to write specific answers. The result differs from other information resources in three major ways and meets all of the criteria described above: · The database is comprehensive in the specialties that have been completed. · The information is accessible within 10 to 15 seconds because the system is easy to use and searching is intuitive. · Specific «recommendations» are made so that the user knows how the author manages a particular problem. All of this information is fully referenced and the abstracts are available within UpToDate for all of the references that have abstracts. · The entire program is continuously update so that none of the information is more than four months out of date. · The program can be accessed from your desktop or portable computer. We can also include other kinds of information as they become available. As an example, UpToDate now includes a complete version of the four Dialysis Outcomes Quality Initiative (DOQI) guidelines that have been published by the National Kidney Foundation. The value of this approach has been recognized around the world by physicians and by multiple major national societies. UpToDate is an official educational program of or is sponsored by the American Society of Nephrology, the American Thoracic Society, the Endocrine Society, the American College of Rheumatology, the American Gastroenterological Association, and the American Medical Association (pending for primary care). One question that we are often asked is how we manage the updating process. Physicians intuitively recognize the large volume of important new information and the difficulty in getting authors to update their information in a continuous manner. We have solved this by hiring Update Editors who are highly trained specialists. The Update Editor is responsible for reading the literature in his or her specialty (including the relevant basic science literature) and making certain that this information gets into the program. A TOUR OF UPTODATE The current CD has complete sections in nephrology, hypertension, cardiology, endocrinology, diabetes mellitus, pulmonary disease, critical care, rheumatology, and an almost complete section in gastroenterology and hepatology. As noted above, the rest of internal medicine should be completed in the next year. The remainder of this section will briefly show you how UpToDate can be used to answer the question of the treatment of focal glomerulosclerosis. Similar questions could be asked in any of the above specialities. One begins by starting the program, which brings up the Search car (fig. 1): In addition to permitting you to perform a search, the Search card also shows in a «Did you know?» section on the top right the most important new information (as selected by the editors) that has been published since the previous CD-ROM. Each time the program is started, a new topic is presented. We will begin the search by typing in «focal glomerulosclerosis» (fig. 2). Two matches are noted: focal glomerulosclerosis and collapsing focal glomerulosclerosis. The first term, focal glomeruloscle- Fig. 1. 11 BURTON D. ROSE Fig. 2. Fig. 4. rosis, is selected by pressing the F1 key or by clicking the mouse on this term. This will bring up the List of Matches which includes all of the Topic cards in UpToDate that discusses some issue related to this disorder (fig. 3). Clicking on the modifier treatment in the bottom left narrows the search from 26 to 3 topics (fig. 4). Clicking on F2 chooses the Topic card «Treatment of primary focal glomerulosclerosis». We are now at the core of UpToDate, on the Topic card that contains the information we want (fig. 5). This information is written de novo for UpToDate; it is not a review taken from somewhere else and is not a series of abstracts. Our experts have reviewed this topic for you. They have identified the major issues with which you need to be familiar and the important studies that have been performed. This is followed by a set of recommendations on how to proceed in the average patient. Fig. 5. Fig. 3. The author's name is apparent (clicking on it will bring up to academic title of the autor) as is the text field, the references field, and the date of last update (May 5, 1998). The first paragraph begins with the important issue that one must distinguish between primary and secondary focal glomerulosclerosis before reading further on treatment. If you are not certain as to how to make this distinction, you can click on the phrase (See card «Causes of focal glomerulosclerosis») to go to that card (fig. 6). Every card in UpToDate is fully referenced. Furthermore, clicking on the reference citation in the text (such as 1 in the first paragraph) will bring up the MEDLINE abstract if there is an abstract (fig. 7). There are currently almost 50,000 abstracts in UpToDate. There are also almost 6000 graphics in the 12 UPTODATE IN NEPHROLOGY. A WAY OUT OF THE TEXTBOOK AND MEDLINE MORASS Fig. 6. Fig. 8. Fig. 9. Fig. 7. program. Clicking on the show histology phrase in the second paragraph will bring up a series of histologic pictures of focal glomerulosclerosis (fig. 8). Clicking the mouse anywhere in the title field of the Topic card brings up a table of contents for the card (fig. 9). This shows both the first and second headings in the text and all of the graphics on the Topic card. Clicking the mouse on the heading «Clinical distinction between primary and secondary FGS» takes us to that section in the text (fig. 10). Once was are certain that the patient has primary focal glomerulosclerosis, we can return to the treatment card. Clicking in the title field reveals a table of contents of this card, showing that all of the major therapeutic alternatives are discussed (fig. 11). Fig. 10. 13 BURTON D. ROSE Fig. 11. Fig. 12. This brief tour has shown how quickly you can get an authoritative, up-to-date answer to a particular clinical question in just a few seconds. Space precludes showing the other features of UpToDate which are summarized below: · All of the information, including text, references, abstracts and graphics, can be printed and distributed to house staff and referring physicians. · Users can get one hour of category I CME credit for every hour they use UpToDate. · There is extensive use of graphics including graphs of important studies (fig. 12), histologic pictures, radiographs, electrocardiograms and movies (such as real-time echocardiography); all of the graphics can be easily imported into a slide-making program (such as PowerPoint) and used for lectures. · A series of tests have been included and more are being developed to permit self-learning. These include renal pathology tests, ECG tests, and Gram stain tests. NOTE: The autor is a founder and major shareholder in UpToDate. BIBLIOGRAFIA 1. Covell DG, Uman GC, Manning PR: Information needs in office practice: are they being met? Ann Intern Med 103: 596, 1985. 2. Osheroff JA, Forsythe DE, Buchanan BG y cols.: Physician's information needs: analysis of questions posed during clinical teaching. Ann Intern Med 114: 576, 1991. 3. Haynes RB, McKibbon KA, Walter CJ y cols.: Online access to MEDLINE in clinical settings. A study of use and usefulness. Ann Intern Med 112: 78, 1990. 4. Wyatt J: Computer-based knowledge systems. Lancet 338: 1431, 1991. 14