Three years ago, after devoting several years to administrative medicine and business, I decided to return to full time clinical pediatric practice. Although relieved that my clinical judgment remained intact, I found that much had changed in clinical pediatrics, especially with the array of new drugs and dosages to treat pediatric problems. My re-entry into clinical medicine motivated me to explore my options for handheld prescribing technology, and I became an early Epocrates subscriber.
The Epocrates suite of products has expanded dramatically over the last two years in response to the needs of practicing physicians. I now routinely use the Epocrates Rx Pro® premium drug reference, Epocrates SxDx disease reference, and Epocrates Lab diagnostic reference in the course of my daily patient encounters. I’ve also had the opportunity to sample Epocrates’ continuing education application, MobileCME. Together, these comprise the application suite called Epocrates Essentials.
Essentials is aptly named in that this suite of applications has become, in my view, the gold standard for mobile medical resources in the marketplace. Although there are a number of alternative products available, none has the accuracy, ease of use or integrated features of Essentials. In the past, I relied on textbooks and frequent trips to the office or home computer to obtain clinical and diagnostic materials. With Epocrates, I now have essential diagnostic and prescribing reference information immediately available to me at the point of care.
All references and tools within Essentials are tabbed, allowing easier access to needed information.
Under the Rx tab, I can look up information on over 3,300 brand and generic drugs, including dosing, contraindications, and cost information.
In my practice, consistently accurate drug dosing is essential to eliminate or reduce medical errors. Epocrates provides pediatric dosing for most medications I prescribe to my patients; to save time, I have set “Peds Dosing” as my default Rx screen. Tapping on any underlined, highlighted medication launches a weight-based dosing calculator, which is medication specific. All the physician needs to do is input the medication strength or liquid formulation, the child’s weight, and the dosing interval – the dose is accurately calculated and instantly displayed. Medication safety precautions for pregnant or breast-feeding mothers, invaluable for the pediatrician, are also available.
Within Rx, there is a tool called MultiCheck, which enables me to check for adverse drug-drug and drug-herbal interactions among up to 30 medicines at a time. Running a MultiCheck is an instantaneous, one-step operation that provides indispensable information for my patients who take multiple medications.
One of the newest Epocrates applications is Epocrates SxDx, a revolutionary integrated disease diagnosis/treatment reference (Dx tab) and symptom assessment tool (Sx tab). This unique tool incorporates symptom assessment to develop an age-specific differential diagnosis, encompassing over 1200 diseases and clinical conditions. This symptom-based approach facilitates clinical decision-making at point of service. Once observed symptoms, pertinent lab values and history are keyed in by age, sex, and duration, a comprehensive list of diagnoses in Epocrates Dx are instantly displayed. Given these parameters, both common and rare diagnoses can be displayed. Detailed descriptions of each diagnosis are displayed, including signs and symptoms, causes, useful diagnostic tests, and treatment approaches including medications. Related topics can be cross-referenced at the touch of a button. Many of the references displayed allow for easy cross-tabbing to other applications within the Epocrates database. For example, when medications for a specific condition are displayed, a dosing calculator (especially useful for my pediatric patients) can be easily accessed. By scrolling through the list of possible diagnoses, the most accurate diagnostic determination can often be made. In my experience, this application provides a superb support tool to the seasoned clinician. However, it is especially helpful to the physician in training, as it helps the student or resident doctor synthesize what can appear as disparate symptom complexes, and helps her to zero in on the most appropriate, yet not always apparent diagnosis. I use this new application frequently in the course of my daily patient care, and have used it with great success during teaching rounds with my students. An example using bronchiolitis in infants is detailed below in the following screens.
| Initial symptom lookup | Common diagnoses |
| Treatment algorithm | Specific diagnostic/treatment parameters |
Under the Dx tab, I also have the ability to directly access scientifically-valid, bullet-point monographs for more than 1,200 diseases and conditions, many of which apply to my pediatric patients. Eocrates Dx is based on Griffith’s 5-Minute Clinical Consult, but unlike other versions of the 5-MCC, Eocrates Dx is frequently updated and expanded.
Using Dx, basic clinical and diagnostic information, surgical and medical treatment options, patient education and monitoring tips, and key preventive care information are all instantly available. Unlike stand-alone programs, Dx provides direct links to other references within Essentials, so that tapping on a ‘drug of choice’ instantly launches Rx, which provides up-to-date information on the corresponding drug. From there, it’s a snap to cross-reference other medications for the clinical condition.
Selecting the “Lab” tab launches the Epocrates Lab application, which provides the user with references to hundreds of diagnostic laboratory tests, either individually or by panel. The program offers interpretation of abnormal values, and cross-links to both Epocrates Rx and Epocrates Dx applications. In addition, useful pricing and Medicare reimbursement information is available, as are tips for collection and preparation. As with other Epocrates apps, Lab is updated frequently with a touch of your HotSync button.
The application has been updated to make the use of Epocrates ID seamless. Clicking on the “ID” tab launches the integrated infectious disease application. This tool is invaluable in that the clinician can cross reference antimicrobials by system, specific organism, or by the drug itself. Integrating ID with Rx enables me to make consistent, rational medication choices, and ensures appropriate dosing for my pediatric patients.
I also use the Tables tab frequently. As with all Epocrates information, this section is updated frequently, so I can be assured of the most current, scientifically-valid data on a variety of topics, such as immunization schedules (including catch-up schedules), travel immunizations, normal pediatric vital signs, steroid comparisons, and comprehensive PALS algorithms.
Finally, by clicking on the ‘black bag’ tab, the application calls up a menu of tools, including MedMath, the MobileCME™ learning system, and optional free MedTools® (e.g., temperature conversion calculator).
MedMath includes over 30 medical calculators, e.g., body mass index calculator.
One recent addition to the Epocrates product suite is a unique, timesaving application – MobileCME. This is the only program available for busy physicians on the go to obtain continuing medical education credits using a handheld device. In partnership with Johns Hopkins and others, MobileCME, available for free with any Epocrates mobile product, creates an easy-to-navigate environment where brief, up-to-date articles, organized by specialty, can be accessed, and CMEs obtained using your PDA. Articles generally run from 5 to 30 screens followed by a series of 4 to 6 questions. You can select from 15 clinical specialty areas, and have available courses from any or all of those specialties downloaded directly onto your handheld. By completing the article and answering a short series of questions, CME credits are earned and automatically tracked. Articles within each specialty provide author and reference information, are updated frequently, and appear as “New,” “Done,” or “Active,” the latter designation appearing should you be interrupted during the course of reading the article or completing the questions. Articles can further be sorted by status or title, another convenient feature. To obtain your CME credits, you simply check the box to select the appropriate number of credit hours, and HotSync your device. By doing so, credit hours are submitted and tracked, and a certificate of completion is emailed to you. I frequently access CME articles during my lunch hour or during down time in the office – not only a terrific learning experience, but a free and convenient way to earn CMEs!
Although I was initially concerned about patients’ and families’ reactions to my using a handheld device at point of care, I quickly discovered their reactions to be unequivocally positive – from the perspectives of being reassured of proper drug selection and dose, and the general high-tech feel of their office visit.
Epocrates Essentials is the quintessential, all-in-one clinical reference application suite for the practicing physician. It’s been redesigned to take up less space on your handheld device, HotSyncs seamlessly and rapidly to allow for biweekly updates, and provides accurate, integrated information in the palm of my hand. I have fully integrated Essentials into my daily office routine, and use it any number of times in a typical practice day. I recommend the Epocrates product suite to my colleagues without reservation.
Philip D. Goldstein, MD, MPH, FAAP Updated 2.2006