Beyond Evidence-Based Medicine: Information Management

By Zachariah Deyo, Pharm.D., PGY2 Ambulatory Care Pharmacy Resident, University of Maryland

The amount of medical information is increasing exponentially in a variety of forms.  Information is available faster than we are capable of mentally digesting.   For these reasons, it is important to develop a personal system to triage new information.   Additionally, the number of new drug therapies is continually increasing, the scope of pharmacy practice is broadening and the expectations of our profession are growing.

In an ideal world of medical information management, clinicians can obtain valid and relevant information that is available with the least amount of work.   Slawson and Shaughnessy explore information mastery in an article entitled Teaching Evidence-Based Medicine: Should We Be Teaching Information Management Instead? (Academic Medicine. 2005;80:685-9).  Technology is a useful tool to organize information and alleviate the amount of work involved in its management.  It can be used as part of a system to decrease the time, money and effort required to obtain information, answer questions and build knowledge.  Current resources include free or paid subscription services that summarize medical research and drug information.  Examples of these resources that may be useful to pharmacist’s include: Pharmacist’s Letter, JournalWatch, Pharmacist’s FirstWatch, MedScape, MedWatch and Wallstreet Journal-Health.  Electronic tables of contents (eTOC) are available from a variety of peer reviewed journals across multiple specialties.  Professional organizations offer list-serves to network with colleagues and experts to ask and answer clinical questions.   This list is by no means complete and myriad resources exist.  Their utility may vary based on ones practice, skill level or interest.  Additionally, to manage them in a central location most can be linked to an email account.  As an alternative, really simple syndications or RSS feeds can be used with a variety of “readers” to manage resources.  Some readers offer the ability to track reading and subscription trends and offer recommendations based on browsing in an effort to pick and choose what is most relevant to ones practice.  Readers can also be used to link to blogs and professional websites.  Also, social networking sites such as facebook and Twitter can be linked to some of the resources previously mentioned.

I was introduced to feed readers as a pharmacy practice resident.  My reader is a useful tool to manage the constant influx of medical information.  As I became more familiar with information management resources, I also began to think of the importance of exposing pharmacy students as well as practicing clinicians to these new tools.  After taking several courses in biostatistics and literature evaluation (as a student), during my residency I was required to take analysis of information to another level.  Should we be incorporating knowledge management strategies into the Doctor of Pharmacy curriculum?

I found several interesting publications on this subject.  The first was an article by Phillips and Glasziou (Postgraduate Medical Journal. 2008;84:450-3) which highlights the importance of keeping up with clinical evidence while in training.  These authors give several reasons :  the need to learn evidence-based medicine(EBM) skills, developing a system that helps manage the volume of new information and helping patients ”get better sooner.”  The importance of quality patient-oriented evidence is also discussed.  The article includes an explanation of the difference between “just in case” and “just in time” learning.  Although the authors write that both are beneficial the former is much more inefficient and information overload can be attenuated by using filtered resources.  Key resources are discussed to help clinicians stay up to date.  A four step approach to EBM including asking questions, acquiring information, appraising evidence, and applying results is explained.  The authors conclude with the goal of developing lifelong learning habits.

Slawson and Shaughnessy (Academic Medicine. 2005;80:685-9) discuss helping students, residents, and clinicians develop skills beyond EBM.  The authors point out that although critically evaluating medical literature is an essential skill, clinicians (in training and practice) must be able to find, evaluate and use information at the point of care.  The authors describe a curriculum that contains three levels of education based on experience and practice.  The three core skills they describe are: selecting tools for “keeping up”, selecting the appropriate hunting tool, and developing patient-centered, not evidence centered, decision making.  In helping students incorporate these skills and tools into their daily lives we foster lifelong learning.

In a subsequent article, Shaughnessy (American Family Physician. 2009;79:25-6) describes how to set up a system for keeping up.  The system  filters information and leads to answers that are valid, efficient, evidence-based, and patient oriented.  This is “system” is often referred to by the acronym POEM (patient-oriented evidence that matters).   Phillips and Glasziou write that focusing learning on information that is directly relevant to patients produces “better” clinicians.  Even the best tools offer little benefit unless you access them on a regular basis.  It can be challenging to find enough time in the day to check email, let alone a feed reader.  By exposing students to these resources early in their professional development we instill habits that will carry into their professional lives.

My recent trip to the American Society of Health-System Pharmacist Midyear Clinical Meeting re-enforced my thoughts on this subject.  I attended an excellent continuing education (CE) session titled: In Case You Missed It: Top Papers in Medicine 2009 (http://www.softconference.com/ASHP/sessionDetail.asp?SID=155655).  This was a great session.  After the conference I thought how true it is that we cannot rely solely on annual meetings and CE to meet the cognitive demands placed on our profession.  Our goal should be aware of and read important papers soon after their publication.  Technology in the form of feed readers and other resources is just one of many tools that can be incorporated into our practices.  Moreover, we must introduce these tool during the education of current and future pharmacists.

I challenge educators in all fields to explore new technology in keeping up with information.  These concepts can be applied to any professional practice.  If you are already familiar with or use these resources, that’s great.  Share them with your students and residents.   But don’t be afraid to let students teach YOU something about these new technologies.   These new technologies are not a replacement for biostatistics or literature evaluation but rather a supplemental tool.