With the long-awaited electronic version of the venerable medical student/resident Tarascon Pocket Pharmacopoeia was released in a Medscape version on September 21st, 2000, Palm users now have a choice of first-rate free pharmaceutical references: ePocrates qRx, first out the door, vs. the new electronic form of the tried-and-true Tarascon Deluxe Pocket Pharmacopoeia. While convenient for any user, these products are all the more important with the recent attention to reducing medical errors.
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For me, the reason to use a bedside pharmacopoeia is to be able to rapidly check salient details of a drug or drugs before deciding on a course of therapy. I generally learn about the drug elsewhere in detail, but do not expect to remember much of the details such as the different dosing regimens, much of the drug interactions, and some of the adverse effects or precautions, until I have used the drug several times. Therefore, as a Family Practice resident, when I was deciding to buy a hand-held computer, I wanted an up-to-date electronic pharmacopoeia to replace my trusty, but easily mislaid Tarascon Pocket Pharmacopoeia. I bought a Pen Computing (magazine) to see what was available, saw the PalmGear HQ ad, then ePocrates, and the choice between Windows CE and Palm was then obvious. I looked forward to the day when I could use an electronic version of the pocket Pharmacopoeia, though, mostly due to it's convenient tables, such as with steroids. Since then, I use ePocrates daily, and it's drug interaction lists have literally saved lives for me. (For example, during an ICU rotation, with an acutely hypotensive patient already on 3,500 mg of fosphenytoin, to whom we did NOT give dopamine due to the interaction shown for dopamine with phenytoin.)
After having used ePocrates for 9 months on my Palm IIIx, I just gave ePharmacopoeia a workout for the last week. I can honestly say that ePocrates is still the more useful of the two programs for me, due to it's clear and concise format, drug interactions and thorough adverse reactions for each drug, and renal dosing. I use it in clinic right in the exam room, as well as on the wards and in ER. I've used ePharmacopoeia in the last week, but preferred Epocrates when busy.
However, the Tarascon ePharmacopoeia does have some features that ePocrates could learn from, such as more extensive over-the-counter (OTC) information, and the structure in place for electronic prescribing to easily be incorporated. Over time, both companies will undoubtedly learn from the other, refining, and copying each other's features. Therefore, here I will review Tarascon in detail, after giving a summary of ePocrates as the standard for comparison, followed by a comparison table. I am not even attempting to review the PDR or LexiDrugs/Apothecarium, due to never using these larger, costly programs.
Basic Product Summaries:
ePocrates - the Palm standard for comparison
ePocrates, in my opinion, is probably the most important hand-held program on the market to date. Over 100,000 physicians have downloaded this pharmacopoeia, with about 400 new physicians each day using the software, according to the Epocrates web site.
To get ePocrates, you go to ePocrates.com, and go through a registration process that is free, but requires your medical license number and basic professional information to register. From there, the software installs itself on to your computer (Mac or PC). On PC's, a HotSync Internet conduit is installed that will automatically check for and upgrade the drug database every time you HotSync without any other user interaction required. This adds a minute or so to HotSyncs, but in my experience, usually results in drug withdrawals being shown within a couple days, and new drugs within a month. Additions to information on drugs already in the database, such as pediatric dosing are made this way as well. (A monthly, non-automatic database update is available as well for those without Internet access on their HotSync computer, or Mac users).
A monthly e-mail informs users of the recent updates, and what to expect in the near future. Currently planned enhancements for October 2000 include pricing info on each drug from Drugstore.com, description of tablet forms, multiple-drug interaction tool, and in November 2000, an infectious disease product (ePocrates qIx).
ePocrates is a company started from the ground up to make a pharmaceutical database (qRx) suitable for practicing physicians, residents, and medical students, and eventually expand into other medical informatic applications. It has always been free, in part due to sponsorship by 3-Com/Palm Inc., as a "killer-application" to induce physicians to buy Palms. (It worked for me!) Echoing the Palm philosophy, it is lean and simple, with no graphic adornments, but rapidly accessible "list view" information on over 1,600 drugs, most being prescription-only, with common OTC's as well.
When you start the program (I have it assigned to my address button, so it only takes a button push) you simply see a list of drugs. Using Graffiti, you enter the name, and with each successive letter, the list moves closer. Usually three letters or so will bring up the drug to just tap on to go to the monograph. The interface is modifiable through Options-Preferences, so that you can start by looking at drug categories if desired, and go to the drug through a drug category screen first, so you see similar drugs too, similar to Tarascon's Pocket Pharmacopoeia (paper).
Every drug has FDA, and non-FDA (denoted by asterisks) indications and dosing listed together. A small menu at the bottom has options for all the other varied information on the drug. Adult and pediatric dosing are separate on different screens, but renal dosing is on the main screen. My favorite ePocrates feature is the drug interactions screen, which lists the interacting drugs. Tapping on a drug will show the particular associated interaction (I was unable to save screenshot of this "pop-up). When leaving ePocrates, starting it up again will take you back to the drug list, with the last drug accessed already high-lighted to be easily tapped on.
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ePocrates Wish List:
One of the most useful aspects of the Pocket Pharmacopoeia during a busy call night was the multitude of concise clear tables. ePocrates only includes a few tables listed under the Class "Other", but these are concise and useful, including regimens for the treatment of H. pylori, emergency contraception, endocarditis prophylaxis, and therapeutic drug levels for aminoglycosides, cardiac drugs, anti-convulsants, and others. However, the concise tables of narcotic and steroid equivalencies, pediatric rehydration solutions, immunization schedules, and so many others in the Pocket Pharmacy, are notably lacking. This may not be of significance to veteran practicing physicians, but for students and residents, is a significant advantage of the Pocket Pharmacopoeia. This deficiency isn't cured in ePharmacopoeia either, as it doesn't include many of the best tables of the paper edition, and presents them as lists anyway.
Fortunately, on the Palm, this deficiency is easily remedied by making your own "call notebook." This is easily done using SmartDoc or a similar doc reader/editor on the Palm, or on the desktop in Microsoft Word, with the PalmDocs plug-in. (For examples, see my Labs-DJ package, and scores of others here or at Palmgear.com.
Neither of Palm pharmacopoeae addresses antimicrobial spectrums and recommendations as yet like the venerable Sanford Guide does, though commercial packages are available here and on PalmGear. Epocrates promises to remedy this with qID in November, but details are sketchy. ePharmacopoeia has basic information in it's lists, but not in table form.
Medscape's Tarascon ePharmacopoeia - paper veteran, but rookie on the Palm
Medscape's Tarascon ePharmacopoeia is the new, free, electronic version of Tarascon's Deluxe Pharmacopoeia, which retails from Tarascon's website for $17.95 (Tarascon.com). In electronic form, it is distributed only by and on Medscape (Medscape ) an excellent commercial Internet information and marketing site for medical professionals.
It is distributed in a 1.5 MB download co-packaged with Teal Doc (a shareware Palm document reader that you are requested to pay $16.95 for if you use it, despite the "free" Medscape Mobile claim) and MedCalc, a free medical formula calculator (that they didn't ask to distribute according to the author, but did not violate his distribution terms either.) You must first be a registered Medscape User (free) and enter a bit more information to register as a Medscape Mobile user. The download is simple, to either Mac or PC, and double-clicking on the file runs the installation of all three programs, which worked without a hitch. No conduits are installed, so HotSyncs don't require Internet access, and just back up the database each time, taking about the same time as does Epocrates (a couple extra minutes).
As to the other programs, trying to delete the Medscape Reader disabled ePharmacopoeia on my Palm, so it is stuffed away in a "Storage Only" page with the ePocrates AutoUpdate program. MedCalc is an excellent tool that I also use every day, to calculate Body Mass Index, Creatinine Clearance (for the renal dosing guides in Epocrates), peak flow percentages, and many other formulas. It is also available on PDAMD, with the most recent versions on PalmGear HQ with more formula's always being added to the versions on PalmGear. Therefore I didn't install MedCalc, as I already use the most current version.
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(Common Drugs List)
Finding Drugs
When the program is started, the drug class (category) screen comes up, with several tabs on the side to choose from alternatively. While the Medscape ePharmacopoeia page claims-
"See an entire drug summary on the first screen, eliminating the need to scroll or tap through multiple screens to get the information you want"
I found otherwise. Multiple taps are required to get to a drug initially. Because there are no start-up options, if you exit from a drug monograph, re-starting ePharm brings you back to the start screen again, requiring the same several steps of getting to the drug again. Forms of the drug are on a different screen than the dosing recommendations. That being said, getting to the drug monographs is a bit cumbersome, but easy and will probably be streamlined in future versions. I usually just went to the Drug list, but a nice option with Tarascon is the Common list, to which you can add frequently used drugs (see example above). Choosing a drug is easy, using either Graffiti or tapping on the letters, a welcome benefit to new Palm users. The drug information monograph then rapidly appears.
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Monographs
"Tarascon Bar" - Each drug first shows the "Tarascon bar" (my term) and any "black box" warnings, or the adult sheet if no warnings. This bar is displayed at the top of all screens, and shows the metabolism type, pregnancy class, lactation class, controlled DEA schedule, and relative price. Clicking on any of these items brings up basic information on it, similar to ePocrates. (i.e. descriptions of pregnancy class, DEA schedules, and price range legend for $ signs). Furthermore, the Back and Main buttons take you back one level, to either the Common or Category page, or to the start-up screen again, much like the ePocrates Class and Home buttons.
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The drug information lists first the FDA approved indications and dosing, and then very clearly, the non-FDA approved uses. This is one benefit over ePocrates, which simply denotes non-FDA uses with an asterisk, which is explained in menu choice Abbreviations, but is easily over-looked or forgotten. Other interesting information may be included, such as warnings about renal dosing or adverse reactions or drug interactions, but these are sporadic and very incomplete, compared to ePocrates. In the example above, only a brief listing of the precautions with vancomycin is listed, compared to the extensive lists from ePocrates, and minimal drug interactions.
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Similarly to the paper PDR, and unlike ePocrates, you have to click on the Forms tab to see the actual tablet sizes for drugs. Pediatric dosing and indications are on a different sheet, as are Notes which lumps a lot of information into a short space, but does not come close to the amount of information that Epocrates' many sheets of information on each drugs have.
Other Aspects of ePharmacopoeia
Rx pad
In exploring ePharmacopoeia, the user finds an "Rx" tab on every drug sheet. Tapping this brings up a "Rx Pad coming soon" sheet, that promises to include wireless transmission of prescriptions (without HotSyncing) integrated with the drug database. Other features anticipated are integration with local formularies, drug interactions, stock quotes, e-mail, and Internet access. Similar to ePocrates in-progress efforts in these areas, this is significant with the push to reduce mistakes. In Washington state, for example, a recent legislative proposal would have required all prescriptions be typed or electronically submitted, though this was turned down in favor of requiring prescriptions be legible.
Tables
I eagerly looked forward to the electronic version of the Pocket Pharmacopoeia due to the many tables I missed, although I have since made my own versions, or downloaded similar ones in Doc format. Therefore, I was dismayed to see the poor versions included in the electronic version. If I had paid for ePharm expecting the paper tables, I would have returned it based on the ones included. Starting with the lame interface (you can't scroll down the page using the up-down button) you see many but not all of the tables in the 1999 paper Pocket version. (I don't have a 2000 or a Deluxe). Clicking on the tables reveals that many are double-spaced, and none are in table format any more. Narcotic and steroid equivalencies are missing altogether. The antimicrobial drug class lists are decent, but are not real tables, and don't begin to approach those available on the Palm such as Redi-Reference - Infectious Disease 9.200 on PDAMD and PalmGear HQ. In all, I found the "tables" that are lists are a real disappointment, compared to the paper versions, or other Palm products, since Tarascon has such good source material to use.
Drug Database Updates
This is still an open question. With the paper version, annual updates are provided. Medscape's page hints at "timely" updates, but it is hard to find any definite commitment to it. With the excellent reputations of both Medscape and Tarascon, I expect they will be able to carry out this expectation, though only time will tell.
Conclusions:
Both Medscape's Tarascon ePharmacopoeia and ePocrates have prescribing information for drugs you don't have memorized. Both anticipate wireless electronic prescriptions writing. However, in terms of timely use at the bedside, I find ePocrates far superior with it's detailed drug interactions, cautions, renal dosing, adverse reactions, and cleaner interface. After this review is done, I will be deleting ePharm from my cramped Palm, to make room for other products to try again, and the inevitably larger version of ePocrates coming out soon. However, I will continue to watch Medscape, as the next version of ePharmacopoeia is sure to be much improved. I think that for people who want the reassurance of Tarascon's name, and already know the drugs they use inside and out, ePharmacopoeia is not a bad choice. In fact one of the other third-year residents in my program is switching to ePharm. If I had a Visor with a Springboard, I would keep both. My only advice to people who choose ePharm, is just to be sure to memorize details of new drugs elsewhere, so you will know what to be careful for!
Author: David L. Jarvis, MD 10/1/2000, Appleton, WI
Links:
ePocrates.com
Tarascon ePharmacopeia
PDAMD.com
Palmgear.com
Tarascon.com
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