Use of PDA Medical Information Resources by Kenyan Family Medicine Residents to Answer Clinical Questions

Bruce Dahlman, M.D. M.Sc.Development Director

Institute of Family Medicine, Nairobi

Consortium on Global Health and Mobility

MDH Energy Drive Meeting Complex8 September 2010

Objectives

Discuss the influence of personal digital assistant (PDA)-based medical information resources on how Kenyan residents answer clinical questions and patient management plans.

Discuss the potential for improving patient outcomes by using PDA-based medical information at the point of care (POC)

Explore the potential of PDA-based, synthesized knowledge management resources to provide decision support information to majority world primary care health professionals

Consider the synergies with similar patient care-prompted questions for refugees and immigrants to Minnesota

Motivation for Pilot Study: Kenya Point of Care Health Info Study

Family Medicine Residency philosophy Reflective practice; learner-centered approach Seek answers prompted by clinical situations

Poor decision support information availability Especially in rural areas – the “internal digital

divide” between urban and rural” Especially few majority world-derived studies

Master of Science, Health Professions Educ. Thesis requirement

Motivation: African Health Workers Shoulder . . .

25% of the global disease burden in 11% of the world’s population with only 3% of

global health workforce

and just 1% ofhealth care resources

WHO (2006) The global shortage of health workers and its impact. Retrieved from http://www.who.int/mediacentre/factsheets/fs302/en/ index.html

Methods – Study Design

Study Design Three Phase, Trial Study Design Intervention: Print handbooks and PDA with

medical information resources

Phase I (6 weeks) PDA with study instrument NO medical information resources A Control Phase

Methods – Study Design

Study Design Phase II (6 weeks)

PDA with study instrument Print version of 3 Oxford handbooks, BNF,

Clinical Evidence, AMA Desk Reference with diagnosis algorithms

Phase III (6 weeks) PDA with electronic versions of above Phase II

resources PDA version of DynaMed database

(www.ebscohost.com/dynamed)

Methods – Subjects and Sites

Study Population All clinically active postgraduates in FM

8 residents from all three years

Study Sites Teaching Hospitals of Moi University Family

Medicine Residency Programme AIC Kijabe Hospital of 220 beds – 2 registrars Webuye District Hospital of 200 beds – 6 registrars

Methods – Data Collection

Data Collection Pre-study survey

Demographics Baseline health information use

Study Instrument 9 questions PDA-based PenDragon® questionnaire

Log ≥ 2 information seeking events/day in each phase

Data analysis Descriptive statistics: frequencies, means, standard error Phase comparisons: F-test for fixed effect

Pre-study Survey

Question Agree or Strongly

Agree

Neutral, Disagree Strongly disagree

I carry some resources with me as I work 100% 0%

I have resources that I keep and use at home 100% 0%

I bring my home resources to the hospital/clinic 25% 75%

I would be concerned for the security of my books at the hospital/clinic

50% 50%

I would be concerned for the security of my computer at the hospital/clinic

75% 25%

I have no secure place to put my resources 50% 50%

I would be hesitant to use a handbook or other resource in front of a patient

37% 63%

I feel patients who see doctors looking things up question their competence

25% 75%

I feel confident to perform a PubMed search 87% 13%

Study Instrument Questions on PDA

1. SUBJECT of the query – Major disciplines

2. Extent of COLLEAGUE consultation

1=none, 5=exclusive

3. FORMAT used (primarily)Colleague, Computer/CD-ROM, Web, PDA, Print

4. CATEGORY of resourceColleague, Database, Formulary, Guideline, Handbook, Journal, Textbook

Sub-item – Actual resource used

Study Instrument 5. How well did the resource answer the question?

1 = Not at all, 5 = Completely6. How did the information alter the prior plan for care?

1 = Confirmed prior plan, 5 = Significantly altered prior plan and patient outcome as a result

7. Where used?W

ith patient, clinic/hospital, library, home

8. When used?W

ith patient, same day, that evening, later

9. If …could not be implemented, what was the reason?Resource not available; Patient not available; Intervention not necessary; Combination

Clinical Subject Consulted

Clinical Speciality (Subject) N Per Cent (%)Behaviour Health/ Psychiatry 25 2.0Community/ Public Health/ Dental 8 0.7Infectious Disease 159 13.0Internal Medicine 485 39.6Obstetrics and Gynaecology 148 12.1Paediatrics 166 13.5Surgery 208 17.2Other Total 23 1.9

Format of Resource Comparison

Format of resource

Phase I Phase II Change

N 442 398

Colleague 13.6 7.3 -6.3

Computer 16.3 4.3 -12.0

Internet 24.0 11.1 -12.9

PDA 0 41.7 +41.7

Print 46.2 35.7 -10.5

Restricted from loading own programs onto PDAs in Phase IComputer and Internet use reduced – replaced by PDA usePrint still consulted – usually later in the evening

Format of Resource - Graphed

Category of Resource

The Influence of PDAs

How well did PDA-based medical information resources answer residents clinical questions?

How well the question is answered by resource format in PDA phase

Format Mean Standard error

Colleague 4.02 0.20

Computer 3.89 0.22

Internet 4.08 0.19

PDA 3.93 0.17

Print 4.14 0.18

Scale: 5 = Completely, 4 = Well, 3 = Fair, 2 = Poorly, 1 = Not at all or couldn’t find an answer.

F = 1.72, p = 0.14 – No statistical difference

The Influence of PDAs

How did PDA-based medical information resources influence patient management?

Knowledge gained altering prior plan of care in PDA phase

Format Mean Standard error

Colleague 3.08 0.28

Computer 2.33 0.31Internet 2.38 0.25PDA 2.64 0.22Print 2.47 0.23

5 = SIGNIFICANTY altered prior plan AND patient OUTCOME4 = SIGNIFICANTY altered prior plan3 = SOMEWHAT altered prior plan2 = Was NEW information but made NO CHANGE in plan1 = CONFIRMED your prior information/plan

F = 2.63, p = 0.034 Sub-analysis: Colleague was significant diff.

Study Conclusions

Resources on a PDA format can significantly affect plan for care in 20%

PDA information resources significantly change outcome in 4.2%

Colleagues answers altered plan for care significantly more than other formats

Sub-analysis: Knowledge gained altering prior plan of care in PDA phase

Format N% Altered

Outcome (5)

% Significant

Change (4)

%Total

4 + 5

Colleague 29 10.3% 27.6% 37.9%

PDA 166 4.2% 19.9% 24.1%

Computer 17 0.0% 17.6% 17.6%

Internet 44 0.0% 15.9% 15.9%

Print 142 0.7% 26.1% 26.8%

5 = SIGNIFICANTY altered prior plan AND patient OUTCOME4 = SIGNIFICANTY altered prior plan

Time to Finish Search during PDA phase

F = 28.45, p = <0.0001 5 = POC 1 = Next day

Format MeanStandard

error% (N) Point of Care

Colleague 4.48 0.18 69.0% (20/29)

PDA 4.17 0.11 42.8% (71/166)

Computer+Internet+Print 5.9% (12/203)

Computer 3.11 0.21 7.0% (10/142)

Internet 2.96 0.15 0.0% (0/17))

Print 3.64 0.12 4.5% (2/44)

Study Conclusions

PDA-based resources move the decision to the point of care 42.8% of the time versus 5.9%

Print handbooks are limiting – can only carry two at a time

Of PDA resources, the synthesized knowledge database was preferred category – used 66.3%

Time to Finish Search – Same Resource

Handbook (Phase II) PDA (Phase III)Title N %PoC %SD N %PoC %SDBMJ Clinical Evidence 15 0.0 26.7 1 0.0 100

British Nat’l Formulary 12 16.7 58.3 14 42.9 35.7

Oxford Acc. & Emerg. 7 14.3 28.6 8 12.5 62.5

Oxford Medicine 49 30.6 28.6 20 5.0 50.0

Oxford Specialities 23 17.4 34.8 25 8.0 60.0All 106 20.8 33.0 68 14.7 52.9

PoC = Point of Care SD = Same day

Where Search Done

WHERE did you consult/use your primary resource? (using

comparable titles)

Format of resourcePrint (phase II) PDA (ph. III)

N % N %Point of care - with the patient 20 24.1 15 34.9Hospital/ clinic, but not with patient 15 18.1 11 25.6

POC/Hospital/clinic 35 42.2 26 60.5

Resource room 12 14.5 3 7.0Hospital library 7 8.4 6 14.0Home 29 34.9 8 18.5

Resource/ Library / Home 488 57.8 17 39.5

Reasons for inability to implement knowledge gained - all phases

Reason unable to implement N = 1222

N and percent of reasons given% of total response

N % all% w/o subjects

16 & 19

Resource (test, drug) not available

29 14.5 22.0 2.4

Patient can’t afford 63 31.5 12.2 5.1

Res. not necessary 23 11.5 2.4 1.9

Patient not avail. 62 31.0 41.5 5.0

Resources & patient not available 17 8.5 9.8 1.4

Other 5 2.5 12.5 0.6

Total 199 99.5% 99.4% 16.4%

Larger study done in Rwanda

Study Population 60 Residents in Anesthesia, FM, IM, OB/Gyn,

Pediatrics, Surgery 5 Faculty in Anesthesia, OB/Gyn, Pediatrics,

Surgery Study Sites

Teaching Hospitals Butare Kigali

Rwanda Study – Clinical Subjects by Family Medicine Residents

Clinical Speciality (Subject)Family Medicine

Residents

N %

Behavioral Health/ Psych 2 1.5

Comm/ Public Hlth/ Dental 3 2.3

Dental 3 2.3

Infectious Disease 25 18.8

Internal Medicine 14 10.5

Obstetrics and Gynecology 42 31.6

Pediatrics 17 12.8

Surgery 25 18.8

Other 2 1.5

Total 133 100.0

Rwanda Study – Format of Resource

What FORMAT of a resource did you use?

Total

Phase I Phase II

N % N %

Computer/ CD-ROM/eTALC 190 21.40 88 11.94

Colleague/consultant EXCLUSIVELY 169 19.03 100 13.57

Internet resource or site (+ wireless connection)

206 23.20 58 7.87

Personal digital assistant (PDA) 64 7.21 430 58.34

Any PRINT resource 214 24.10 39 5.29

Other 45 5.07 22 2.99Total 888 100.00 737 100.00

All changes are statistically significant, excluding “other”

Realities: Challenges

Technical Internet bandwidth Downloading & syncing Platforms

Acquiring the product Purchase process Getting it in-country Warranties and help lines

Relevant resources from Africa Not included in most resources

Realities: Successes

Technology desired, accepted and used Even Western-based

Partners Dynamed

Synthesized EBM Links to journals, resources

Skyscape Selection of resouces

Dr. Companion British resources known to former colonies

Realities: Future Implications

What technology and medical information resources can best inform/facilitate EB decision making in resource poor settings? What is the technology future?

Smartphones MicroSD cards Common search engine across categories

What is the information future? Africa relevant resources Other regional relevant resources Secondary surveillance and aggregation

The Goal: Digital African Health Library

Synthesized knowledge management resources to provide decision support information to majority world primary care health professionals?

Accurate, relevant information to improve health outcomes

Elimination of outcome disparities Retention of national health professionals

where they are most needed

Realities: Future Implications

How can the lessons learned in Kenya be applied to the immigrant and refugee populations?

Are their synergies to collaboration?

Asante sana!

E: bdahlman@aimint.netM: 612.877.2181