Dx + Rx = New Synergy at ePocrates
Daniel B. Hier, M.D.
We all had that experience back in medical school when a senior professor lectured that "diagnosis come before treatment". He or she reminded us that appropriate treatment can begin only in the setting of accurate diagnosis. The new clinical software suite from ePocrates has taken that old adage to heart by creating synergy. This suite combines ePocrates' extensive drug monographs (now called ePocrates Rx) with a concise but powerful diagnostic reference work (now called ePocrates Dx). The content of ePocrates Rx is the drug information that clinicians are already familiar with in ePocrates Rx and ePocrates Rx Pro. The diagnostic content for ePocrates Dx comes from the acclaimed book and PDA program Griffith's 5 Minute Clinical Consult. ePocrates has not simply bundled two PDA programs together, but rather, has tightly integrated the two programs into a powerful reference work that will be of tremendous value to busy clinicians who need concise and up to date information as they see patient on rounds or in their offices.
ePocrates Rx and ePocrates Rx Pro
ePocrates Rx is already the most used PDA medical software. Clinicians are familiar with its authoritative monographs that are organized by both brand name and generic name. For each drug, information is available as to indications (with dosing recommendations), dose sizes, routes of administration, contraindications and cautions, adverse reactions, drug interactions, retail drug costs, manufacturer, safety in pregnancy data, as well as mechanism of action, and mode of metabolism. The ePocrates Rx monographs can be searched by either brand name (e.g. Biaxin), generic name (clarithromycin), or by drug class (antimicrobial).
MultiCheck is another useful and easy to use feature of the Rx module. Two or more drugs are selected in this module and then checked for drug interactions. For example, when I ran a possible interaction between Coumadin and Zithromax, I found that use of Zithromax in patients on Coumadin could cause a rise in the INR and that increased monitoring might be necessary.
Within ePocrates Rx, you can also customize which health plan and hospital formularies are loaded and displayed, so that you can select drugs for your patients based upon their pharmacy plans. In areas with high HMO penetration and complex drug benefit programs, the formulary feature can be a tremendous help to physicians who are struggling to prescribe covered drugs for their patients. One nice thing about ePocrates Rx is that if a drug is not listed as covered by a formulary, ePocrates Rx will recommend another similar drug that is covered by the patient's formulary.
In addition to the drug monograph and formulary information, ePocrates Rx Pro includes access to the ePocrates ID infectious disease guide, alternative medicines, clinical tables and guidelines, an integrated weight-based dosing calculator (adult and peds) and a full medical calculator (MedMath).
ePocrates Dx
The addition of Griffith's 5 Minute Clinical Consult (5MCC) enhances the power and utility of the drug monographs within ePocrates. Like 5MCC, ePocrates Dx is organized into over 1000 clinical topics ranging from amyloidosis through multiple sclerosis to zinc deficiency. Topics are arranged in alphabetical order for easy searching. For each topic, there are short sections covering "basics", "signs/symptoms", "causes", "diagnosis", "treatment", "medications", "related topics"," notes" and" miscellaneous" information. For example, when I searched under "miscellaneous" for multiple sclerosis, I was able to retrieve the ICD-9-CM code as well as basic information about cause and diagnosis. The most powerful feature is clearly the link between drug recommendations in 5MCC (ePocrates Dx) and the drug monographs in ePocrates Rx (and ePocrates Rx Pro). Under multiple sclerosis, I found that baclofen could be used for spasticity, oxybutynin for urinary incontinence, methylprednisolone for acute attacks, and interferon beta-1a for prevention of exacerbations. By drilling down on any of the drugs, I retrieved their associated drug monograph in ePocrates Rx with information of dosing, side effects, costs, and indications.
The ePocrates Dx module has over 30 integrated tables with valuable tabular information about a variety of medical conditions. For example, 5 year survival rates for ovarian cancer by stage and failure rates for different methods of contraception are shown below.
The ePocrates ID Module
The ePocrates ID module is included with ePocrates Rx Pro and can be accessed from the main screen in the ePocrates Clinical Suite. The opening screen can be customized to open by "system", by "bug", or by "drug". The default is to open the application by "system". For example, I selected CNS from the system menu, drilled down to encephalitis, and then got recommendations for empiric therapy with acyclovir and ceftriaxone. I could have drilled down further on either drug to seamlessly launch into the corresponding ePocrates Rx Pro drug monographs.
The Tables Module
The Tables Module is also included with ePocrates Rx Pro and can be accessed from the main screen in the ePocrates Clinical Suite. It contains a wealth of handy information that is frequently needed but often hard to find. Included in these tables are vaccination guidelines for children and adults, HIV medication protocols, narcotic equivalent dosing, AHA guidelines for advanced life support and resuscitation, guidelines for anti-hypertensive therapy, the Glasgow Coma Scale, and other useful tables.
Other Functionality
The ePocrates Clinical Suite has several other useful features including an integrated weight-based dosing calculator (adult and peds) and a powerful MedMath calculator that lets you quickly calculate useful values such as corrected serum sodium and calcium, ideal body weight, body surface area, and body mass index. In addition, the DocAlert feature allows the downloading of breaking news from the FDA and other health agencies when synchronizing your ePocrates software via the Internet with the ePocrates website. These alerts are stored on your handheld within the ePocrates Clinical Suite for future reference.
Platform and Installation
Although ePocrates has created both Palm OS and Pocket PC versions of ePocrates Rx Pro, the ePocrates Rx and ePocrates Dx modules are currently only compatible with the Palm OS. I easily downloaded the application from the ePocrates website. On my Treo 300 Palm OS device, ePocrates Rx Pro and ePocrates Dx took up 5.1 MB of my total 16000K of free memory.
Performance
On my Treo 300, the application ran swiftly and smoothly. It loaded instantaneously. Switching between major modules (Rx, Dx, ID, and Tables) was quick. The default setup is for a splash screen to come up between module changes that gives the usual disclaimers as well as the last download date. This splash screen can be turned off to speed switching between modules. I encountered no bugs and the system never crashed.
Customizability
The ePocrates Clinical Suite is surprisingly customizable to the way you like to work. You can select which module you wish to have as your default screen upon opening the application (Rx, Dx, ID, or MedTools). Within ePocrates Rx, ePocrates Rx Pro and ePocrates Dx, you can also select which information screen you wish to have as your default upon opening the specific module. For example, you can set ePocrates Rx drug monographs to default to the "Drug Interactions" screen and you can set ePocrates Dx disease monographs to default to the "Treatment" screen. Left-handed users can also move the scroll bar to the left hand side of the screen.
The Bottom Line
The seamless integration of the 5MCC with ePocrates Rx is an impressive achievement for ePocrates. This integration creates synergy between two very good PDA products and makes the ePocrates Clinical Suite a powerful clinical tool. Rich diagnostic and therapeutic information is now combined in a single clinical tool that is concise, up to date, and easy to use. ePocrates is beginning to tip their hand. They are moving out of the pure drug monograph distribution business into the knowledge management business. They are providing clinicians with the knowledge they need in order to manage and treat their patients effectively. The ePocrates Clinical Suite for the Palm OS is a significant step in this new direction.
Dr. Hier is Professor of Neurology and Rehabilitation at the University of Illinois Medical Center in Chicago. He serves on the Electronic Medical Record Committee for the hospital. He is currently pursuing an MBA degree with specialization in health informatics.
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