A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

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A Guide to Primary Care of People with HIV/AIDS Chapter 18: Keeping Up-To-Date: Sources of Information for the Practicing Clinician 18 Websites targeting consumers enable them to directly access scientific and clinical information and to pose questions to experts. These websites empower patients by helping them to better understand their disease and its manifestations and by enabling them to advocate for their own health and to more fully participate in decisionmaking about their care. See Table 2-1, Information Resources for Patients, in Chapter 2. Thinking ahead: can personal digital assistants (PDAs) help you keep up? A revolution in healthcare information technology has begun that brings information resources directly to the provider at the point of care, whether at the bedside or during the clinic visit. Mobile computing through handheld devices, such as personal digital assistants (PDAs), are now available and have begun to change the practice of medicine by facilitating capture of data and retrieval of information. PDAs (eg, Palm, Pocket PC, Visor) are now used as clinical tools for reference, prescribing, coding and patient education (see Table 18-4). Table 18-4. Useful PDA References* General medical references (available commercially) Drug prescribing databases, including drug interaction data (available at no cost) Antibiotic prescribing guides (available at no cost) Prescriptions Compiled abstracts and CMEs * Websites accessed 1/04. Harrison’s On-Hand: http://harrisons. accessmedicine.com Merck Manual: http://www.merck.com Washington Manual of Medical Therapeutics, 30th edition, for PDA: http://www.lww.com DSM-IV: http://www.appi.org/pda.cfx Bellevue Guide to Outpatient Medicine: http://www.bmjpg.com/Bellevue ePocrates: http://www2.epocrates.com mobilePDR: http://www.pdr.net Tarascon ePharmacopoeia: http://www.tarascon.com Johns Hopkins Antibiotic Guide: http://www.Hopkins-abxguide.org ePocrates ID: http://www2.epocrates.com Ephysician.com: http://www.ephysician.com Advanced PCS: https://physician.advan cepcs.com/ ZIXCorp: http://www.zixcorp.com/caredel/ JournaltoGo: http://www.journaltogo.com eMedicine: http://www.emedicine.com (also has patient education materials) Currently, the greatest advantage of carrying a PDA is having medical resources at your fingertips. Through a function that uses a cradle to connect with a website via a personal computer, the provider’s PDA can “synch” with a master database that is maintained and updated regularly. Transfer of information is easily accomplished with PDAs through “beaming.” By pointing the PDA at another PDA and tapping on the appropriate prompts, data are quickly transported into the other PDA database. Similarly, information can be beamed to a printer, which is a particularly useful feature for quickly printing patient information or prescriptions. As PDA technology rapidly evolves, the utility and efficacy of handheld computing will similarly expand. Potential new uses of PDA technology include portable access to MEDLINE, full text journal articles, information searches, comprehensive information storage, and point-of-care access to guidelines, algorithms, and other decisionmaking tools to enhance the quality of care. PDA versions of patient tracking systems and coding references (http://www.meistermed.com) have also been developed. Ultimately, PDAs will be used in conjunction with electronic medical record systems, with information being “beamed” between the two systems. This powerful application of PDA technology will permit comprehensive individualized patient data files that can include current and past medical information, laboratory data, and even reminders for providers to perform periodic preventive health or monitoring tests. Providers who have not already taken the first step, purchasing and using a PDA, should become acquainted with this important new technology as an important source of clinical information and aid to patient management (see Table 18-5). Table 18-5. Websites for Learning More about PDAs or Obtaining Software* Websites that categorize resources/libraries University of Alberta http://www.library.ualberta.ca/subject/ laboratory/pdahealth/index.cfm Or click on PDA Resources at http://www.library.ualberta.ca/ Duke University Medical Center Library http://www.mclibrary.duke.edu/respub/guides/pda/index.html Or look up PDAs at http://www.mclibrary.duke.edu. Arizona Health Sciences Library http://educ.ahsl.arizona.edu/pda/index.htm U VA Health System PDA Support http://www.healthsystem.virgin ia.edu/internet/library/services/computing/pda/ Or look up PDA support at http://www.healthsystem.virginia.edu/internet/library. E Carolina University Laupus Library PDA Support http://www.hsl.ecu.edu/departments/outreach/pda.cfm Websites for downloading of software (often at no cost) American College of Physicians PDA Portal http://www.acponline.org/pda/clinical_references.htm Healthy Palm Pilot http://www.healthypalmpilot.com Palmgear.com http://www.palmgear.com PocketGear.com http://www.pocketgear.com Handango http://www.handango.com tucows http://pda.tucows.com/ * Websites accessed 1/04. 154 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
A Guide to Primary Care of People with HIV/AIDS Chapter 18: Keeping Up-To-Date: Sources of Information for the Practicing Clinician INTEGRATING HIV SPECIALTY INTO PRACTICE Making it stick: how can you integrate new information into clinical practice? Numerous resources at the fingertips of providers enable them to obtain up-to-the-minute information about new developments or management strategies for HIV care. However, even the best-educated provider cannot assure that quality of care will be achieved through access to the most recent standards and current information unless the system in which care is provided has been adapted to integrate that information. Strategies for developing and sustaining systems to support information can be implemented at the local level through individual actions and through quality improvement programs. A variety of resources provide assistance in successfully integrating current information into HIV care. Most notably, the decision support framework of the chronic care model developed by the University of Washington has been used to improve care delivered by Ryan White CARE Act-funded clinics (see Figure 1-1 in Chapter 1). Quality improvement strategies based on this model include the following principles: • Embed current guidelines in the care delivery system. • Establish linkages with key specialists to ensure that primary care providers have access to expert support. • Provide continuous skill-oriented interactive training programs for all staff to update knowledge of current guidelines. • Provide feedback to providers on their use of guidelines. • Incorporate community-based staff (social workers and case managers) into decision support. • Educate patients about guidelines. One example of the application of these strategies is conducting chart audits in order to benchmark practices and feed the information back to providers. Other examples are using flow sheets or checklists to embed guidelines into practice and developing simplified versions of guidelines for providers and patients. The most successful strategies to incorporate guidelines into systems of care are those that include reminders at the point of care or decisionmaking. An important rule of thumb is that multiple interventions work better than just one. For more information on quality improvement, see Chapter 17. How do you develop the experience needed to qualify as an HIV specialist? Multiple studies show better outcomes when providers managing patients have expertise in HIV (see Table 18-6). In the absence of a formally recognized subspecialty society devoted to HIV medicine, government agencies, professional societies, and academic institutions have developed definitions of HIV specialization in order to develop policies, standards, and regulations, and to monitor the quality of care provided to persons with HIV (see Table 18-7). Definitions of HIV specialists generally focus on two major areas, experience and HIV CME credits, and also require that experience be current and that knowledge be updated annually. Generally, requirements for experience in the care of patients with HIV range from 10 to 20 patient-years of experience. All definitions emphasize currency of experience and education, given the rapid pace at which HIV clinical management standards change. Table 18-6. Resources on HIV Expertise and Patient Outcomes Gerbert B, Moe JC, Saag MS, et al. Toward a definition of HIV expertise: a survey of experienced HIV physicians. AIDS Patient Care STDS. 2001;15:321-330. Keitz SA, Box TL, Homan RK, Bartlett JA, Oddone EZ. Primary care for patients infected with human immunodeficiency virus: a randomized controlled trial. J Gen Intern Med. 2001;16:573-582. Kitahata MM, Koepsell TD, Deyo RA, Maxwell CL, Dodge WT, Wagner EH. Physicians’ experience with the acquired immunodeficiency syndrome as a factor in patients’ survival. N Engl J Med. 1996;334:701-706. Kitahata MM, Van Rompaey SE, Shields A. Physician experience in the care of persons with HIV infection is associated with earlier adoption of new antiretroviral therapy. J Acquir Immune Defic Syndr. 2000;24:106-114. Stone VE, Mansourati FF, Poses RM, Mayer KH. Relation of physician specialty and HIV/AIDS experience to choice of guideline-recommended antiretroviral therapy. J Gen Intern Med. 2001;16:360-368. Willard CL, Liljestrand P, Goldschmidt RH, Grumbach K. Is experience with human immunodeficiency virus disease related to clinical practice? A survey of rural primary care physicians. Arch Fam Med. 1999;8:502-508. 18 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau 155
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