Evidence-based medicine in the Palm of your hand

I would like to practise more evidence-based medicine, but doing so has been quite a challenge. One of my biggest difficulties has been that I could not remember many of the information nuggets needed to make an evidence-based decision at the bedside. Well, now I can, thanks to my hand-held brain extender.

As a community family physician, I am always able to remember the 9 DSM IV criteria for depression simply because I see this condition so often in my practice. However, remembering all the criteria for other diagnoses, such as attention deficit disorder, is challenging: ADD/hyperactivity has 18 inclusion criteria. This information is easily accessible on my Palm — I can call it up and go through it with my patient. Doing a structured psychiatric interview has become much easier and much less of an exercise in often frustrated recall.

I have a Framingham calculator (STAT Cardiac Risk, www.statcoder.com) to estimate my patients' risk of cardiac events over the next 10 years; this lets me point out how much their risk decreases if they quit smoking. The calculator also helps me decide when medication for cholesterol is warranted.

The single most useful clinical program on my Palm is a drug information database, ePocrates (www.epocrates.com). This has a comprehensive, searchable list of drugs that provides both generic and trade names. Adult and pediatric dosages are given, along with side effects. Determining whether it is safe to prescribe a drug during pregnancy is easy, and there is a list of drug interactions. The latest version allows searches for interactions among several drugs. This is very useful with my elderly patients, who are often taking 5 or more drugs. There is also a section for making notes on each drug, which allows me to enter code numbers for medications restricted by my provincial drug benefit program.

I use a medical calculator list (MedCalc, http://netxperience.org/medcalc ) to determine a patient's body mass index, predicted peak flow, gestational age or other clinical parameters. I also have a pregnancy calculator (PregPro, www.thenar.com/pregcalc) that stores the patient's LMP, gestational age and due date. It shows me her expected weight gain, fetal weight and biparietal diameter, and it prompts me to order lab tests at the appropriate time. This means I no longer have to use a pregnancy wheel during each prenatal visit.

I have a set of medical rules, MedRules (downloaded from healthy palmpilot.com), which allows me to check off criteria and obtain the probability that various clinical problems will be present. I am familiar with several of these, but the complexity of most of the lists made them difficult to remember and to use at the bedside. If an asymptomatic woman is worried, for example, about her risk of breast cancer, I can now bring up the Gail model in MedRules, enter her data and give her an estimate of her risk over the next 5 years. Most younger women will have a minimal 5-year risk, and seeing the actual number may be very reassuring for the patient.

My patients have not found my Palm to be intrusive. Indeed, they appreciate the extra information that I can now bring to their health care. I think this little instrument will find a permanent place at the future bedside. It already has at mine. —

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