Care Provider Toolkit--A Rough Guide

Eric Rose, M.D.
Clinical Assistant Professor, Department of Family Medicine, University of Washington
Clinical Informaticist, University of Washington Physicians Network

If you ever watch the TV show "ER," which in many respects is reasonably accurate in its portrayal of current medical practice, you'll notice that the attendings and residents on the show--even the students--never seem to need to look things up when they're seeing patients. They're amazing, walking repositories of massive amounts of medical knowledge, ready with the right workup plan, the right diagnosis, the right treatment--instantly, every time.

Well, guess what--everyone, including attendings, needs to look things up. All the time. If you want to be an effective, efficient, clinician, you need to incorporate the process of acquiring new medical information into your patient-care activities--whether it's the dosing for digoxin, where to stick that needle when you're putting in a subclavian line, or the latest research on hormone replacement therapy and breast cancer--without missing a beat.

Fortunately, it's a lot easier for your generation than for the one that came before. Whereas you used to have to rely on whatever paper-based sources were available (textbooks, "pocket references" you carry around with you, your preceptor's file drawer of journal articles), now you have available, through the World Wide Web, the UW Health Science Library's Care Provider Toolkit (CPT), an extensive collection of medical knowledge resources--in electronic format--that rival the contents of a small medical library. Which creates a different problem--how do you find the answer to your specific clinical question, quickly, amidst the sometimes overwhelming variety of resources available?

That's what this brochure is about. Consider it a "Lonely Planet" guide to the Care Provider Toolkit (and a few other web-based resources)--an opinionated, biased, sometimes unduly critical or dismissive, take-it-with-a-grain-of-salt kind of guide, written by one who has traveled extensively in the region, which may come in handy when you're experiencing the medical-knowledge equivalent of being stuck in Kathmandu when it's getting dark and you need to find a place to sleep and some yak butter tea. As with any guidebook, some travelers won't want to take a step without it, while others will flip through it and then toss it aside as they intrepidly explore on their own.

PS. This is a work which I plan to keep updated as resources in the CPT are added or modified; the latest version will always be found on my website, at: http://faculty.washington.edu/momus/cpt/guide.htm. Comments and suggestions are always welcome; you can e-mail me at momus@u.washington.edu.

This guide presumes a basic knowledge of how to use a computer and surf the web. If you need help with that, check out http://www.pawisland.com/mainmenu.html which will show you the basics.

A note on file formats with web-based resources. Most of the resources you'll reach through the CPT are in "HTML" format, which means they can be easily (and quickly) displayed with your web browser (Netscape, Internet Explorer, etc.). Occasionally you'll come across a link to information in a different format, like a Microsoft Word file, and the browser will prompt you to state whether you want to save the document to your hard drive or view it right away--usually you'll want to choose the latter, as you can always save it after viewing it if it turns out to be useful. One other file format is worth mentioning is the "Portable Document File." These files have the suffix ".pdf" and are viewed with a program called Adobe Acrobat Reader, which can be downloaded for free from the web. Most websites that link to .pdf files will also have a link to download the Acrobat Reader for those who don't already have it on their computers, but if they don't, here's a link to the download page:

The CPT (http://healthlinks.washington.edu/toolkits/care_provider.html) is part of "Healthlinks," a larger website operated by the UW Health Sciences Library. It (the CPT) is basically a links page designed to provide easy access to clinically useful information. However, it's different from many other "links pages" in that many of the resources linked to are pay sites that are subscribed to by HSL, and are made available only to UW-affiliated persons. The CPT page--as of February 2000--looks like this:

As you can see, the resources in the CPT are arranged in 6 categories--for the most part it's just click-on-the-resource-you-want-and-go. The categories are...

See the funny icons? They're actually worth knowing about. The

indicates a "restricted" resource, i.e. one not available to any old schlemiel surfing the web, because UW paid $ so you & I could have it. You don't really need to worry about this issue, unless you have trouble connecting to the resource in question, in which case if you click on the

next to it, you'll get some information on the technical aspects of how the restricted access works. Those students who will need access from remote sites where the computer they're working on isn't directly conntected to the UW will probably need to connect using a "Proxy Server"--see http://healthlinks.washington.edu/help/connecting.html. If you run into trouble, call or e-mail HSL (see the website for contact info). The

icon links to some information about the resource that only a librarian would care about (OK, that's a bit of an exaggeration, but for the most part you won't go there).

In the frame on the left of the screen, there are three links on the left that you'll probably end up using sooner or later.

One of the most important things to know about any knowledge resource is how quickly can you get your answer. This has a lot to do with how well the information is organized and presented, though of course, the level of detail makes a big deal as well. There are times when you just need to know what to do, fast, so you can get back to seeing the next patient. There are times when you have more time, and can take a while to peruse a moderately detailed reference. And (hopefully), there are times when you will want to cuddle up with a very detailed reference, at leisure, and absorb some nitty-gritty "raw" medical literature, with all its ambiguities and nuances, and really master a topic.

Like a said, you need to know which knowledge resources fall into which categories. So, in the following commentaries, I've assigned one of three icons to those knowledge resources in the CPT that I am recommending. A given resource may be labelled with more than one icon, e.g. if it provides access to different types of information that correspond to the different icons. If a listed resource doesn't have an icon next to it, that's because I don't think it that the link to it will be of much use to you (note that I don't say that it's because the resource won't be useful, just the link, because there may be other links to it which will be useful--yes, that is confusing, but all will be explained--see below).

The "Rocketeer" indicates a resource to use when you need to zoom to a specific piece of information--you're hopping, no time to waste digesting lots of details, just need the answer to your question--FAST--from someone who's done the digesting for you. This is the Power Bar of the CPT; not suitable as your sole source of knowledge nutrition. Incidentally, the flame in this icon is animated, so if you're reading the printed version of this you're really missing out.

The "Biker" indicates a resource that's intermediate in detail and speed with which you can get through it. It won't just give you an answer with no explanation; you'll find some background, some context, and enough information to educate you beyond the question of how to take care of a particular patient at a particular time. The "Fleur de Lys" was the symbol of the Bourbon dynasty of France and has nothing to do with anything; I just got tired of looking for clip art.

The "Hiker" indicates an in-depth knowledge resource--one that will discuss a topic down at the level of the nitty-gritty minutae of medical knowledge, often including statistical results of individual published studies. This is the kind of thing that you want to make as much use of as you can, as it will educate you both about the topic in question as well as how medical "knowledge" is built step by step from conflicting and ambiguous building blocks. However, you won't get through it fast--you'll mostly want to read these after work, at the kitchen table, with a cup of yak butter tea.

PubMed is a Medline search tool that has a slightly clunky user interface, but is very powerful if you take the time to figure out how to do stuff (like Boolean logic to combine searches, etc.). It's the only way in the CPT to search all of Medline. Medline, of course, is a database that indexes basically every medical journal going back to 1966. You search it when you want to find any kind of article in a medical journal, e.g. clinical trials or review articles on a given topic.

OVID Full-Text Journals provides access to the entire contents of about 40 of the most important medical journals. However, it doesn't make much sense to ever go directly to this link, since it is only one of several different "portals" throught which Healthlinks provides full-text access to medical journals. If you know of a specific journal article you want, it makes more sense to look for the journal where it appears in the list accessed from the "Journals" link on the left, and from there, link to the full-text access portal, be it Ovid, ProQuest, or whatever. If you don't know the article you want, it makes more sense to search all of Medline than to follow the Ovid link, since the latter will only search those 40-some-odd journals for you.

MicroMedex is the only up-to-date drug reference through the CPT (except for GenRx, which is available through both MD Consult and Stat!Ref--see below). It is quite thorough though the user interface could be better. It does have fairly quick access to critical things like doses and information about using drugs in pregnancy. The website also links to a toxicology database, a database that identifies meds by the imprints on a pill, and a not-very-useful set of patient handouts (on general medical issues, not on drugs!)

GenRx is the other up-to-date complete drug reference available through the CPT. You have to go through the MD Consult page to get to is (see below). Other than being a little inaccessible, it's great.

FDRx--Federated Drug Reference was a remarkable achievement in its time which pulled together several separate databases having to do with medications. Unfortunately, it hasn't been kept up-to-date and in its current incarnation (2-2000) is not highly useful.

Managed Care Combined Drug Formulary Guide provides information about which health plans cover which meds in Washington State. It is better than nothing if you need this sort of information but was last updated in 1998 and formularies may have changed a lot since then!

Food and Drug Administration Drug Information--This website really isn't very useful--mostly regulatory info. Some info on recent FDA warnings/drug recalls, etc. Don't go looking here for general drug info, though.

MD Consult--As with most everything else with MD Consult, this is a quality resource. The handouts here are actually from a company called Clinical Reference Systems, are well-written, and cover a very broad range of primary care topics, including handouts on a very large # of medications. The only downer is that you have to type in a username and password and their server is slow!

AAFP Patient Leaflets--The range of topics is limited. If you can find a pamphlet on the topic you're looking for, the quality is very high.

US DHHS healthfinder--This is one of those extensive "links pages" that can keep you clicking forever to find what you need. At least it has a search function. It does have some links to decent material and is a good last resort if you can't find what you need in the two resources above.

EthnoMed--This is a very cool resource, a guide to cultural beliefs and practices--particularly as they pertain to health and medicine--of people from East Africa and South East Asia, who form a large proportion of recent immigrants to Seattle. Definitely worth reading if your clerkship site serves individuals from these parts of the world.

AMA Health Insight--Good material but not printer-friendly; many pamphlets are spread over several web pages.

MicroMedex Patient Leaflets--Short, little detail, designed for use in ER's. Not really worth wasting your time with.

Health Reference Center--Some good material here but the user interface is so clunky it's barely worth it, especially given the availablility of MD Consult (see above)

Cochrane Library--This is the Grand Poobah of all evidence based knowledge resources. It covers a wide array of topics. For each topic, there is a summary of all the available published studies and a discussion of how all their results can be reconciled into a coherent picture and translated into standards of clinical care. For some, they have done "meta-analyses," where they combine data from available studies and re-analyze it to get overall results. The focus of each topic is quite specific, e.g. "Amnioinfusion for preterm rupture of membranes," so look here if you want to know all there is to know about a particular clinical question. If your focus is more broad, like "how do I take care of a patient with preterm rupture of membranes," look elsewhere.

National Guideline Clearinghouse--Now we're talkin'. Seems like everyone and their mama's issuing guidelines these days, and the NGC has got them all. Or at least, the "summary" chapters of them all and links to the entire guidelines (when they're available on the web). This is a great resource if you know of a specific guideline that you need. Be a little careful,,though--all guidelines are not created equal! Just because one has the imprimatur of an organiziation doesn't necessarily mean it's carefully put together or that its recommendations are supported by evidence. One cool feature is the "Compare Guidelines" feature which allows you to compare guidelines on similar subjects side-by-side.

PubMed Clinical Queries using Research Methodology Filters--This is a feature of PubMed (see above) that allows you to "filter" Medline searches according to the focus of the articles in the database, either "therapy," "diagnosis," "etiology," or "prognosis." Your search results then become a search set in PubMed that you can combine with other searches or apply further limits to, e.g. language or type of article. This might be useful in some situations if you're not wanting to retrieve everthing in a given subject area.

University of Washington Physicians Guidelines--OK, I'm going out on a limb here, but give these a miss too. For one thing, some (like HTN & CHF) are out of date, others (like DM & Asthma) are basically just summaries of guidelines from other organizations that are available in more readable format elsewhere. You been warned--nuff said.

TRIP Database--This site ambitiously claims to be a searchable "amalgamation of 26 databases of hyperlinks from ‘Evidence-based’ sites around the world." Unfortunately, there ain't much there. A lot of the search results are bad links. Those that work are often not very useful, e.g. brief summaries of Cochrane systematic reviews instead of the reviews themselves, or summaries of published clinical trials that you could have found through Medline.. Not highly recommended.

Best Evidence--This can only be used if you're physically in the Health Sciences Library.

ACP Journal Club--This includes summaries and discussions of recent important published studies. It is fun to browse but not likely to be useful if you have a specific question in mind, since the topics are hit-or-miss.

Immunization Recommendations--This links to another page of links (oh well), but there you'll find links some useful stuff, like those that follow. The other links on that page are pretty redundant. For some reason they've put links to the US Guide to Preventive Services and the American Academy of Family Physicians' recommendations for the Periodic Health Examination on this page. These are useful documents to wade through if you ever want to know why some things are recommended as part of a "routine check-up" and others aren't (and hopefully someday you will wade through them, but probably won't be references you'll be consulting in the rush of a clinic day. Note that these, and other "guideline"-type docuemnts can be accessed through the National Guideline Clearinghouse website (see above).

HealthLinks Evidence-Based Practice & Guidelines page--Again, a link to a page of links, and this links page is massive! It is sort of an expanded list of EBM & Guidelines links and includes many of those in that section on the main Healthlinks page (i.e. those listed immediately above). There are many interesting links here but few that will likely be of great practical use to you on your rotation. One exception is the "Best Available Evidence" link (see below). In addition, there are links to some important and useful clinical guidelines, e.g. the Public Health Service's "Guide to Clinical Preventive Services" and the guidelines of the AHCPR, but again, if that's the sort of thing you're looking for, you're better off going to the National Guideline Clearinghouse website and using their search function to find something on the topic you've got in mind.

Clinical Nutrition Resource Book--An impressive work, but as it focuses on enteral and parenteral nutrition therapy, it's not one you'll be using much in your Family Medicine rotation. Keep it in mind when you're getting ready for your ICU elective, though...

GeneClinics--Again, really impressive, and again, one you probably won't need every day on a Family Medicine rotation. This has very detailed info on what types of testing is available for various genetic diseases. Actually, it has a lot more, including info about the inheritance patterns, clinical features, etc., for a large number of genetic diseases. Keep it in mind.

Harrison's Online--Just what it says. If you like Harrison's, here it is online (for my money, I'd go with Sci-Am Online--see below). The interface is a little cumbersome, but at least it's just one link and no password to type in like with MD Consult (see below)

Laboratory Test Information--Don't waste your time--all you'll find is the normal ranges, specimen requirements, etc.--not what you want to know, which is, "what does this test mean." For that, you'll want to look in Ravel's "Clinical Laboratory Medicine," a (perhaps too) detailed textbook in the MD Consult collection (see below)

MD Consult--OK, this site is a pain to get into because you have to a) Go initially to the main website before you can access any of the many different resources it provides, and b) the server is slow. BTW, you have to click on the "Open Generic Edition" to get in. Despite these drawbacks, this site is your friend, OK, so just do what I tell ya. Get in the habit of going in there, hanging around, seeing what you find. Seriously. It has a very comprehensive array of excellent textbooks, the full texts of some very key journals (including the "xxx Clinics of North America" journals which, if you hadn't figured out by now, are a great source for well-written, authoritative review articles on just about anything), a great (though VERY detailed) drug reference (GenRx), a great set of patient handouts, and the whole durn thing is searchable all at one fell swoop. It's basically a top-notch mini-medical library. What more do you want, the freakin' computer to pick up your dry cleaning or something? PS. If you're not using the UW Proxy Server (see above), you'll have to e-mail HSL to request a username & password.

Scientific American Medicine Online--This is the textbook that, in the paper version, comes in the big looseleaf binder because they keep updating it all the time, chapter by chapter, rather than all at one fell swoop with a new edition. The online version is nice, though the lack of an index is a bit of a pain.

STAT!REF Medical Reference Library--OK, if MD Consult is the WWF, then Stat!Ref is the WCW. Uh...what I mean is that it's the same concept but with lower-quality material and shoddier execution. The main asset of Stat!Ref are the "Current xxx Diagnosis and Treatment" series, which, to give them credit, are faves with students because they're so concise, and also offer useful chapters on presenting problems, like "Hematuria." In addition, Stat!Ref contains DSM-IV, the definitive reference on how to diagnose (but not how to treat) psychiatric disorders, and Williams Obstetrics, considered by many to be the "definitive" text, but MD Consult has Gabbe's Obstetrics, edited by UW's own Dr. Gabbe, which in my humble opinion is better anyway.

Stedman's Medical Dictionary--If erudition (or good speling) were essential in medicine, half of us faculty would be out on our butts by now. But if you need it, there it is.

University of Iowa Family Practice Handbook--I recommend this reference with caution. In my opinion, it's not kept very diligently up-to-date in many topics and it's a bit too lacking in detail for my comfort. However, it is good for a quick reference, and the fact that it's organized to some degree by symptom, not just by diagnosis, can make it handy.

CINAHL--This is a database of Nursing journals, the equivalent of "Medline" for the Nursing literature. The link actually takes you to the CINAHL page of WebSPIRS, a search tool that gives you access to numerous databases of academic literature, including social work, zoology, etc. This won't me of much use to you in day-to-day practice.

Clinical Calculators--Some of these are useful--they're the kind of things you'll want to bookmark when you find them, so that you don't have to navigate your way through it each time to find what you want. My personal favorite are the calculators on the National Center for Emergency Medicine Informatics page, though the page itself has a busy and difficult layout.

Reportable Infectious Diseases--Reporting reportable diseases probably won't be your responsibility until you're at least at the intern level, but if you want to know about reporting requirements in King County, here ya go.

Medical Center Information Systems--I don't know what this is doing here. Most of the links from this page are inaccessible to the general UW Community, and they aren't really things you'd find useful anyway.

These are just a few of the sites I regularly use in my practice. They aren't on the CPT but are potentially useful for students and residents.

The Dermatology Online Atlas--This is a derm site that has about 10 pictures of every single friggin' derm disease known. Completely useless unless you have some idea of the diagnosis, but if you have a diagnosis name, it's very useful

PDR Online--Just an online version of the PDR which, in case you don't know, is simply drug manufacturers' official information statements ("package inserts") on their drugs. Useful for "official" information on dosing, interactions, blood test monitoring, etc. You have to register for the site, but it's free.

USDA Nutrient Database--Ever want to know how much Calcium there is in Kale? Look it up here! Complete nutritional info on basically every single type of food. Useful when counseling patients on nutrition.


Drug Reference	MicroMedex		MicroMedex
	GenRx		GenRx
Textbooks	University of Iowa FP Handbook	Harrison's Online
		Scientific American Medicine Online
		STAT!REF Medical Reference Library
		MD Consult
Immunization Recommendations	CDC National Immunization Program
	CDC Traveler's Health page
Medline		PubMed	PubMed
Evidence-Based Medicine and Guidelines	National Guideline Clearinghouse	National Guideline Clearinghouse	Cochrane Library
			Best Available Evidence
Patient education	AAFP Patient Leaflets (very quick)	EthnoMed
	MD Consult (not so quick)
	US DHHS Healthfinder (not so quick)
Other resources	Clinical Calculators	PDR Online
	The Dermatology Online Atlas	USDA Nutrient Database

...and just for you, I put in hyperlinks so you can get to them quick. That's it; if you have any comments, questions, suggestions, etc. please drop me an e-mail at momus@u.washington.edu. Happy surfing,

PS.--Take a look at the CPT GUIDE EXERCISES--A set of "real-life" vignettes designed to help you learn your way around the Care Provider Toolkit--Check it out!