PubMed4Hh: A Point-of-Care Mobile App for Evidence-Based Clinical Decision Support for Nurse Residents in Maryland.

Evidence-based clinical decision-making is considered a core competency for professional nurses. However, barriers such as lack of time in clinical practice; information overload; restricted access to resources; lack of evidence appraisal skills, awareness, and knowledge; and unreliable resources prevent them from adopting evidence-based practice. This study examined the usefulness of the PubMed4Hh (PubMed for Handhelds) mobile application for clinical decision-making at the point of care among Maryland newly licensed RNs. Using iOS and Android smartphones, 178 newly licensed RNs participated in a 6-month trial from November 2019 to April 2020. Nurses manually entered free-text queries or used voice inputs on the "Patient, Intervention, Comparison, Outcome" or "askMEDLINE" search engines. The results retrieved were presented as journal article abstracts or short summaries called "the bottom line," designed for quick reading at the point of care. Both Patient, Intervention, Comparison, Outcome and askMEDLINE were rated highly for their usefulness, and participants said they would continue using PubMed4Hh and recommend it to others. Newly licensed RNs had a significantly higher perception of the usefulness of PubMed4Hh when the results of "the bottom line" or abstracts confirmed, led, or modified their nursing skills, knowledge, or the patient's care plan.

Telepathology at the Armed Forces Institute of Pathology: A Retrospective Review of Consultations From 1996 to 1997.

CONTEXT: - Telepathology is the practice of pathology at a distance, transmitting images using telecommunication methods for second opinion and/or diagnostic assistance, or for educational purposes. It may be the only means of consultation for some pathologists. OBJECTIVE: - To retrospectively review and evaluate a subset of telepathology consultations from June 1996 to March 1997, and to determine the concordance between the telepathology diagnosis of the contributor and pathologists at the Armed Forces Institute of Pathology (AFIP), Washington, District of Columbia, as well as the concordance between the telepathology diagnosis and the glass slide diagnosis, when available. DESIGN: - Photocopies of de-identified telepathology reports from the AFIP during a 15-month period between June 1996 and March 1997 were reviewed. Contributor versus telepathology diagnosis was graded as 1 (complete agreement), 2 (partial agreement), 3 (disagreement; usually a diagnosis of benign versus malignant), and deferred. Data were analyzed using descriptive statistical methods. RESULTS: - Of the 262 cases, 194 (74%) were in complete agreement with the contributor's diagnosis, 34 of 262 (13%) were in minor disagreement, and 21 of 262 (8%) were in major disagreement. Diagnoses were deferred in 5% (13 of 262) of cases. CONCLUSIONS: - Using commercial off-the-shelf technology and despite telecommunication challenges during that time, the AFIP demonstrated that telepathology could be conducted reliably.

Evaluation of Android Smartphones for Telepathology.

BACKGROUND: In the year 2014, Android smartphones accounted for one-third of mobile connections globally but are predicted to increase to two-thirds by 2020. In developing countries, where teleconsultations can benefit health-care providers most, the ratio is even higher. This study compared the use of two Android phones, an 8 megapixel (MP) and a 16 MP phone, for capturing microscopic images. METHOD: The Android phones were used to capture images and videos of a gastrointestinal biopsy teaching set of referred cases from the Armed Forces Institute of Pathology (AFIP). The acquired images and videos were reviewed online by two pathologists for image quality, adequacy for diagnosis, usefulness of video overviews, and confidence in diagnosis, on a 5-point Likert scale. RESULTS: The results show higher means in a 5-point Likert scale for the 8 MP versus the 16 MP phone that were statistically significant in adequacy of images (4.0 vs. 3.75) for rendering diagnosis and for agreement with the reference diagnosis (2.33 vs. 2.07). Although the quality of images was found higher in the 16 MP phone (3.8 vs. 3.65), these were not statistically significant. Adding video images of the entire specimen was found to be useful for evaluating the slides (combined mean, 4.0). CONCLUSION: For telepathology and other image dependent practices in developing countries, Android phones could be a useful tool for capturing images.

Evaluation of a smartphone for telepathology: Lessons learned.

BACKGROUND: Mobile networks and smartphones are growing in developing countries. Expert telemedicine consultation will become more convenient and feasible. We wanted to report on our experience in using a smartphone and a 3-D printed adapter for capturing microscopic images. METHODS: Images and videos from a gastrointestinal biopsy teaching set of referred cases from the AFIP were captured with an iPhone 5 smartphone fitted with a 3-D printed adapter. Nine pathologists worldwide evaluated the images for quality, adequacy for telepathology consultation, and confidence rendering a diagnosis based on the images viewed on the web. RESULTS: Average Likert scales (ordinal data) for image quality (1=poor, 5=diagnostic) and adequacy for diagnosis (1=No, 5=Yes) had modes of 3 and 4, respectively. Adding a video overview of the specimen improved diagnostic confidence. The mode of confidence in diagnosis based on the images reviewed was four. In 31 instances, reviewers' diagnoses completely agreed with AFIP diagnosis, with partial agreement in 9 and major disagreement in 5. There was strong correlation between image quality and confidence (r = 0.78), image quality and adequacy of image (r = 0.73) and whether images were found adequate when reviewers were confident (r = 0.72). Intraclass Correlation for measuring reliability among the four reviewers who finished a majority of cases was high (quality=0.83, adequacy= 0.76 and confidence=0.92). CONCLUSIONS: Smartphones allow pathologists and other image dependent disciplines in low resource areas to transmit consultations to experts anywhere in the world. Improvements in camera resolution and training may mitigate some limitations found in this study.

Point-of-Care Estimated Radiation Exposure and Imaging Guidelines Can Reduce Pediatric Radiation Burden.

INTRODUCTION: The steady increase in the use of computed tomography (CT) has particular concerns for children. Family physicians must often select pediatric imaging without any decision support. We hypothesized that point-of-care decision support would lead to the selection of imaging that lowered radiation exposure and improved guideline congruence. METHODS: Our double-blind, randomized simulation included family physicians in the Military Health System. Participants initially reviewed a pediatric hematuria scenario and selected imaging without decision support. Participants were subsequently randomized to either receive imaging-appropriateness guidelines and then estimated radiation exposure information or receive estimated radiation information then guidelines; imaging selections were required after each step. The primary outcome was the selected imaging modality with point-of-care decision support. RESULTS: The first arm increased CT ordering after viewing the guidelines (P = .008) but then decreased it after reviewing radiation exposure information (P = .007). In the second arm radiation information decreased CT and plain film use (P = not significant), with a subsequent increase in ultrasound and CT after the guideline presentation (P = .05). CONCLUSIONS: Decision support during a simulated pediatric scenario helped family physicians select imaging that lowered radiation exposure and was aligned with current guidelines, especially when presented with radiation information after guideline review. This information could help inform electronic medical record design.

Confidence and Information Access in Clinical Decision-Making: An Examination of the Cognitive Processes that affect the Information-seeking Behavior of Physicians.

Clinical decision-making involves the interplay between cognitive processes and physicians' perceptions of confidence in the context of their information-seeking behavior. The objectives of the study are: to examine how these concepts interact, to determine whether physician confidence, defined in relation to information need, affects clinical decision-making, and if information access improves decision accuracy. We analyzed previously collected data about resident physicians' perceptions of information need from a study comparing abstracts and full-text articles in clinical decision accuracy. We found that there is a significant relation between confidence and accuracy (φ=0.164, p<0.01). We also found various differences in the alignment of confidence and accuracy, demonstrating the concepts of underconfidence and overconfidence across years of clinical experience. Access to online literature also has a significant effect on accuracy (p<0.001). These results highlight possible CDSS strategies to reduce medical errors.

Radiation exposure and cost influence physician medical image decision making: a randomized controlled trial.

BACKGROUND: It is estimated that 20%-40% of advanced medical imaging in the United States is unnecessary, resulting in patient overexposure to radiation and increasing the cost of care. Previous imaging utilization studies have focused on clinical appropriateness. An important contributor to excessive use of advanced imaging may be a physician "knowledge gap" regarding the safety and cost of the tests. OBJECTIVES: To determine whether safety and cost information will change physician medical image decision making. RESEARCH DESIGN: Double-blinded, randomized controlled trial. Following standardized case presentation, physicians made an initial imaging choice. This was followed by the presentation of guidelines, radiation exposure and health risk, and cost information. RESULTS: Approximately half (57 of 112, 50.9%) of participants initially selected computed tomography (CT). When presented with guideline recommendations, participants did not modify their initial imaging choice (P=0.197). A significant reduction (56.3%, P<0.001) in CT ordering occurred after presentation of radiation exposure/health risk information; ordering changed to magnetic resonance imaging or ultrasound (US). A significant reduction (48.3%, P<0.001) in CT and magnetic resonance imaging ordering occurred after presentation of Medicare reimbursement information; ordering changed to US. The majority of physicians (31 of 40, 77.5%) selecting US never modified their ordering. No significant relationship between physician demographics and decision making was observed. CONCLUSIONS: This study suggests that physician decision making can be influenced by safety and cost information and the order in which information is provided to physicians can affect their decisions.

A comparison of the accuracy of clinical decisions based on full-text articles and on journal abstracts alone: a study among residents in a tertiary care hospital.

BACKGROUND: Many clinicians depend solely on journal abstracts to guide clinical decisions. OBJECTIVES: This study aims to determine if there are differences in the accuracy of responses to simulated cases between resident physicians provided with an abstract only and those with full-text articles. It also attempts to describe their information-seeking behaviour. METHODS: Seventy-seven resident physicians from four specialty departments of a tertiary care hospital completed a paper-based questionnaire with clinical simulation cases, then randomly assigned to two intervention groups-access to abstracts-only and access to both abstracts and full-text. While having access to medical literature, they completed an online version of the same questionnaire. FINDINGS: The average improvement across departments was not significantly different between the abstracts-only group and the full-text group (p=0.44), but when accounting for an interaction between intervention and department, the effect was significant (p=0.049) with improvement greater with full-text in the surgery department. Overall, the accuracy of responses was greater after the provision of either abstracts-only or full-text (p<0.0001). Although some residents indicated that 'accumulated knowledge' was sufficient to respond to the patient management questions, in most instances (83% of cases) they still sought medical literature. CONCLUSIONS: Our findings support studies that doctors will use evidence when convenient and current evidence improved clinical decisions. The accuracy of decisions improved after the provision of evidence. Clinical decisions guided by full-text articles were more accurate than those guided by abstracts alone, but the results seem to be driven by a significant difference in one department.