In Samuel Luke Fildes' well-known 1891 painting “The Doctor,” the artwork's namesake pensively leans over a sick patient, hand to his mouth in deep thought as family members grieve in the background.
Although hospitalists in 2016 also experience scenarios like this, they have the advantage of several point-of-care information resources close at hand, Bradley Benson, MD, FACP, told attendees at Hospital Medicine 2016.
“This is why I use apps,” said Dr. Benson. “As hospitalists, all of us have been there, that point at which you're agonizing at the bedside and realize this patient is not doing well and, if we just knew more, we might be able to make them better.” Instead of racking their brains or thumbing through countless pages for answers, today's doctors can reach into a modern medical kit—the app store or a website—for instant access to clinical calculators, risk predictors, medication references, diagnostic lab references, and differential diagnosis builders.
Dr. Benson, executive medical director of the adult hospital medicine service and professor of medicine and pediatrics at the University of Minnesota Medical Center in Minneapolis, and J. Richard Pittman, MD, FACP, associate professor of medicine at Emory University in Atlanta, listed their favorite hospitalist apps on the market for conference attendees.
Their judging criteria included an app's usefulness during a week on the wards and how well the tool improved patient outcomes and the overall care experience.
1. Clinical calculators: MDCalc, pmidCALC, QxMD (all free)
These clinical calculators can help a hospitalist solve questions like whether to use warfarin or aspirin for an atrial fibrillation patient, said Dr. Benson. Simply enter a patient's age, sex, and clinical characteristics into MDCalc to come up with a CHA2DS2-VASc score. “What I like about MDCalc is...they actually interviewed the author of the paper in which that calculator was validated” and wrote an article about how the new score was created, Dr. Benson said. “It reminds me that the calculator is only as good as the quality of the study on which it was based.” PmidCALC is another clinical calculator. “These calculator selections never have all of what you need, so bottom line is you're going to need 2, 3, or 4 selections,” he said.
Calculators can also help determine if admission is necessary. Dr. Pittman demonstrated how QxMD Calculate can provide a CURB-65 severity score for a pneumonia patient. “[QxMD] actually has most of the calculators that I use on a regular basis, so if you're going to get just 1, I recommend this one....You still use your clinical judgment, but you do have some support if you want to send this patient home and avoid the readmission,” he said.
2. Risk predictors: NSQIP (hospital membership required), SHFM (free), LACE Index Tool (free)
The next category helps with challenges like a preoperative assessment for shoulder arthroplasty. Using the surgical risk calculator from the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP), a hospitalist can enter patient characteristics and the diagnosis-related group of the procedure to calculate the risk of major surgical complications, Dr. Benson showed. “A lot of the surgeons at your institutions will be enrolled in here and, in fact, their outcomes are what have gone into this calculator,” he said. The Web app allows the user to modify risk within the confidence intervals of the related study's dataset, so physicians can adjust as needed if they believe a particular patient has a higher or lower risk for certain reasons, Dr. Benson said. “And even better, I can have this [report] either e-mailed to the surgeon or printed,” he said. “What I do is copy/paste in my note.”
For patients with heart failure, the Seattle Heart Failure Model (SHFM), a Web app from the University of Washington, is a validated risk assessment tool, said Dr. Pittman. After entering a patient's baseline characteristics, physicians evaluate the likely impact of different interventions. For example, compared to no intervention, a patient's mean life expectancy may increase from 4.2 to 5.7 years with a beta-blocker and from 4.2 to 8.4 years with an implantable cardioverter-defibrillator. “I feel like, in our practice, we spend a lot of time managing people's expectations, often lowering them to a more realistic point...so this is a great tool not only to inform you, but also the patient, of the positive impact these interventions have,” Dr. Pittman said.
When discharging a patient, the Health System Performance Research Network's LACE Index Tool is a validated Web app that can help determine readmission risk, Dr. Benson showed. Physicians can document this result, although ideally even more could be done with it. “The holy grail, for me, is all of this is integrated in my electronic health record [EHR]. If the EHR system just calculated that LACE index for me and triggered postdischarge interventions to reduce readmission risk, that'd be ideal,” Dr. Benson said.
3. Medication/medical knowledge references: Sanford Guide ($30/year), Johns Hopkins guides ($30/year), GoodRx (free), Clinical ORthopedic Exam ($39.99)
The Sanford Guide is a known trusted reference for drug choices and is now available as an app, Dr. Pittman said. “Some people actually still carry the paper version....If ever a book were meant to be digitized, it would be the Sanford Guide,” he said. Similar tools are available in the form of Johns Hopkins guides on antibiotics, diabetes, HIV, and psychiatry.
When deciding which drug to prescribe, physicians may also consider cost. “I don't know about you, but many of my patients are feeling the costs of their health care, and we often have no idea how much things cost. When you prescribe, there's a really cool app called GoodRx,” Dr. Pittman said. “It levels the playing field for patients who do not compare costs at competing pharmacies.” After typing a medication into the app, a physician can compare costs on a map of nearby pharmacies. “The other thing is to look at the dosage, so a 100- versus a 150-mg tab can be 4 times the cost. This really opened my eyes to the racket,” Dr. Benson said.
When you need orthopedic knowledge, the Clinical ORthopedic Exam app is an “example of a stellar multimedia textbook,” Dr. Benson said. The app, citing relevant studies, will provide the diagnostic accuracy of orthopedic tests for a suspected condition and even a YouTube video demonstrating how to perform the maneuver.
4. Diagnostic lab references: ARUP Consult (free)
ARUP Consult is a Web-based guide that can help physicians select the appropriate lab workup for suspected diagnoses. “I realize the choices have changed over time for a lot of these [tests], and this is one of those things I like to, when I see this patient, get up to speed again for the next one,” Dr. Benson said. ARUP Consult also provides links to more information and pertinent guidelines. “I sure like that it is well referenced and, even more, [that it includes] who the medical reviewer was for it and when it was last updated,” he said. “Those, for me, are critical in a field where there's a shelf life on knowledge, so I think having this upfront is a fantastic policy.”
5. Differential diagnosis builders: VisualDx ($99/year)
When the diagnosis is even less certain, as in the example of a patient admitted with visual changes and a palmar rash, an app may be helpful to expand the differential. With VisualDx, a Web-based clinical decision tool, entering the clinical criteria, body part with activity, and details about the rash produce a visual differential diagnosis, Dr. Pittman showed. “So instead of the 1 [initial diagnosis], which was unrealistic—it was syphilis—he and his wife will be so relieved that this is actually dyshidrotic dermatitis,” he said.