Wednesday, December 6, 2017

Relevance of EMR in medical practice: conversational learning in the evidence based healthcare listserv

This blog post is in response to Shimona's query below:

" What is the relevance of EMR to the current practice of evidence based medicine? "

Well I have modified the question slightly as I wasn't able to directly copy paste it from the whatsapp group and I know she is also particular about EBM and so in the conversations in the evidence based list serve below I try to provide her more food for thought on this topic based on an older discussion where I had participated and am fishing out from my email box:

"El 03/11/2011 15:40, Dr. Carlos Cuello escribió:
Quite interesting on how electronic medical records can become a part of observational evidence and apply when there is no other evidence at hand.

Good read

http://www.nejm.org/doi/full/10.1056/NEJMp1108726

--
Carlos A. Cuello-García, MD
Centre for Evidence-Based Practice & Knowledge Translation
Tec de Monterrey School of Medicine
Cochrane Collaboration Iberoamerican branch
CITES piso 3. Morones Prieto 3000 pte. Col. Doctores 64710 
Monterrey, NL. Mexico."



On Thu, Nov 3, 2011 at 10:04 PM, Healingjia@msn.com <Healingjia@msn.com> wrote:
Dear Carlos and Ernesto,
I am also intrigued with this field not only for traditional medical care but also for use in the realm of mental health. this over time could provide patterns that could lead to defining research instead of researchers beating the same dead horse without resurrection tactics from multiple angles it would also cross reference objectively behaviours and medication effects other than psychotropic agents although of course could include these

Amy

Amy Price 
Empower 2 Go 
Building Brain Potential
Sent from my iPad"


On Thu, Nov 3, 2011 at 10:54, Rakesh Biswas <rakesh7biswas@gmail.com> wrote:
The authors have summed it up interestingly...

"Did we make the correct decision for our patient? ...we may never really know. 

“...in the light of experience as guided by intelligence...”
In the practice of medicine, one can't do better than that."

:-)

 "SCMAIL.AC.UK] On Behalf Of Brian Alper MD
Sent: 03 November 2011 02:06 PM

To: EVIDENCE-BASED-HEALTH@JISCMAIL.AC.UK
Subject: Re: Evidence-Based Medicine in the EMR Era

We want the best available evidence at the time we are making a clinical decision.  Ideally we have the best available evidence in a clearly understandable form, including understanding the quality/certainty/limitations of that evidence.

When the best available evidence is observational data from EMR records it would be ideal to have that readily available (with an understanding of its limitations).

In our traditional approaches some clinicians and researchers will seek observational data like this and publish it in the form of cohort studies, case-control studies or case series.  This observational data may then be found by clinicians and may represent the best available evidence for a given concept.  It can also be found by researchers and may stimulate further research and understanding.

In the new model described (this “case report” of using observational data from an EMR for a local decision) the data is unpublished (except for what was shared in this special report) and is otherwise not available for others.  Likewise the clinicians in this example could not find the data that may be available in other EMR records at other institutions, and that data may be similar (corroborating) or different.  It also took the clinicians 4 hours to obtain and analyze the data which is not be feasible for many clinical questions during practice.

Perhaps we will see a future when observational data from EMRs can be obtained without compromising privacy or ownership concerns, compiled from multiple settings, represented in real time to fit specific information needs, and be interpretable with the understanding of its limitations as observational data, ideally presented in context with sharing of more reliable evidence when more reliable evidence is available.

Brian S. Alper, MD, MSPH
Editor-in-Chief, DynaMed (www.ebscohost.com/dynamed)"

"From: Dr. Amy Price<healingjia@msn.com>
Date: Fri, Nov 4, 2011 at 9:10 AM
Subject: Re: Evidence-Based Medicine in the EMR Era
To: EVIDENCE-BASED-HEALTH@jiscmail.ac.uk


Carlos,

I think Brian answered well. In the first instance the concept annoyed me due to an experience where I experienced physicians blindly accepting the printout on an ECG...as a minor finding of variations. Well the patients fingernails were bluish, he could barely stand, was dizzy etc so I sent him to the hospital, later at a surgeon friends home I went to his library and took out the cardiology book and matched the rhythms to the print out. When he asked what I was doing I told him and he said “Oh Amy, only the cardiologists bother with that, I am surprised you can read that”.  They were patterns with labels..a six year old could have gotten it. I apparently made a good call as the hospital took him and he had open heart surgery. This really kind of biased me against EMR as I figure if none of the chart helps existed they would have actually looked at the patient and all the evidence....you know a patient is more than a traffic light and may need help even if the diagnostic doesn’t show in bold or red...I think when there is too much automation perhaps people forget what they once knew...

Really, I only looked at the link because you sent it through and then I started thinking about data mining possibilities, I think the possibilities are impressive and I really appreciate your assistance today in opening a rather firmly closed mind!

Amy "

"From: Rakesh Biswas <rakesh7biswas@GMAIL.COM
Date: Fri, 4 Nov 2011 16:05:53 +0530

To: <EVIDENCE-BASED-HEALTH@JISCMAIL.AC.UK>
Subject: Re: Evidence-Based Medicine in the EMR Era

EMRs/Case Reports contain contextual information about an 'individual' that can have a psychological appeal for most clinicians as we often tend to think in terms of clinical pattern matching/recognition ( as in Amy's ...fingernails were bluish, he could barely stand, was dizzy etc or even ECG patterns for that matter?).

On the other hand current evidence based reviews contain information about a 'population' that is difficult to match with the patient at hand (due to the uniqueness of each individual case) and consequently at times may appear psychologically less appealing to clinicians?

Either way if there were a randomized controlled trial between a combined 'individual and population based information' (as in the evolving EMR model) and just 'population' based information ( as in the current model) to study their effect on clinical decision making in terms of patient related health care outcomes it is more likely that the combined approach would fare better?

:-)

regards,

rakesh


Thursday, September 7, 2017

What is the evidence for emerging therapeutic options for Dengue thrombocytopenia?

Come Dengue season and we find a lot of our patients on papaya juice and recently I noticed some of them on tablets containing carica papaya. Here's a systematic review by Dr Jaykaran https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5108100/ that shows impressive results although with customary caution that more studies are needed. I feel this systematic review is acting as a boon for drug companies setting up shop for carica papaya and it's vital that we discuss this incisively. Currently I am struggling with the terms mean difference,  for example if the study says "C. papaya leaf extract was found to be associated with increase in platelet count in the overall analysis (mean difference [MD] =20.27 [95% confidence interval (CI) 6.21–34.73; P = 0.005]) " should the patient think that carica papaya on an average would increase the platelets by 20,000??! Pranab Chatterjee, Amy Price, Arin Basu, Karthik Balachandran, Subbalaxmi Malladi, SP Kalantri.

The author Dr Jaykaran Charan is also with us here in Tabula rasa. Please enlighten us as to how to explain the meaning of mean deviation in your results to our patients in simpler non mathematical terms.

Dr SP Kalantri :

The authors should have assessed the quality of  individual studies by checking the CONSORT statement for reporting randomized trials. We need to know in the first place the quality of the evidence. http://www.consort-statement.org/

Dr Apildev Neupane

I wish Leaf Extract and fruit intake were interchangeable. 😊.

Dr Jaykaran Charan:

Mean difference is is not important in such studies what is more important is confidence interval of difference. With 95 percent of probability the actual difference of platelet count may lies between 6.21 to 34.73. It can be anything between this range.  The quality of trials were checked by Cochrane risk of bias tool not by CONSORT.

Dr Arin Basu quoting the query :

"Currently I am struggling with the terms mean difference, for example if the study says "C. papaya leaf extract was found to be associated with increase in platelet count in the overall analysis (mean difference [MD] =20.27 [95% confidence interval (CI) 6.21–34.73; P = 0.005]) " should the patient think that carica papaya on an average would increase the platelets by 20,000??"

Dr Arin Basu:

No, it does not mean this. What you are looking at is  the absolute difference of the "differences in mean platelet counts" as in treatment increased the difference by X and controls increased the difference by Y, hence the efficacy of the treatment would be X - Y. Such changes are difficult to interpret. With so much heterogeneity in the studies (I have not analysed the data myself, but based on what the authors reported and DrJaykaran Charan may provide more insight to it), I wonder why did they at all attempt a "meta analysis", rather than discuss the studies in details. There is also no data on the primary end point, i.e., mortality as they did not find any. So, it is justified to state you need more data before you can meaningfully assimilate the available evidence for any clinical practice decision making.


Tuesday, November 15, 2016

50 yrs old man with pain in abdomen since 8 months (CDSS) conversational decision support system 1

Conversational Decision Support:


Comments
Jyoti Sunder Tripathi
Jyoti Sunder Tripathi Pt complaining nausea and vomiting in 1tim....
Swelling of abdomen....ascitis..
Jyoti Sunder Tripathi
Jyoti Sunder Tripathi Aj ki kya planning h....
Fluid tapping? 
Rt?
Arun Chaudhary
Arun Chaudhary Sir actually ..patient k right illic side ..me kuch spots dikh rahe hain n kuch stiffness b feel ho ri h ...
Rakesh Biswas
Rakesh Biswas Thanks Arun yeh patient kya abhi MMW mein hain?
Like · Reply · 1 · April 12 at 9:08pm
Arun Chaudhary
Arun Chaudhary Yes sir ..inko MMW me shift kr diya h ...n sir pt k attender ka kehna h k RT k bad unko fever aa rha h ...
Rakesh Biswas
Rakesh Biswas fever chart dikhayenge inka Arun?
Like · Reply · 1 · April 12 at 9:57pm
Arun Chaudhary
Arun Chaudhary Sir ...aaj se hi aaya h fever ..pehle ka normal chart h ...aaj fever charting krva rha hu n ..sponging b krane ka bola h ..
Rakesh Biswas
Rakesh Biswas Inka IV line mein dekh lena koi thrombophlebitis to nahi. Agar koi IV nahi chal raha hai to nikaal sakte hain. Unke pet dard kaisa hai?
Rakesh Biswas
Rakesh Biswas Arun inka fever chart bhi aajka update kar dena
Arun Chaudhary
Arun Chaudhary Sir ...abhi to koi problem ni h ...ache se so rahe hain ye ...
Rakesh Biswas
Rakesh Biswas Thanks Arun. How is he now subjectively and objectively?
Arun Chaudhary
Arun Chaudhary Sir ...ache h patient ..no complain ..n he is sleeping ...but some swelling on left foot
Rakesh Biswas
Rakesh Biswas Was he sleeping on his left side Arun? Ask Arti to post an image of both his feet so that we can make out the differences in his edema feet.
Like · Reply · 1 · April 14 at 9:01am
Arun Chaudhary
Arun Chaudhary No sir ...he is lying in supine position ...but he fold his legs ...so foot swollen
Rakesh Biswas
Rakesh Biswas How is he subjectively Arti?
Arti Jat
Arti Jat Sir pt. Is stable... normally nausea during walking and no pain in foot
Rakesh Biswas
Rakesh Biswas Is he walking Arti? I always find him bed ridden. Does he walk to the toilet?
Arti Jat
Arti Jat Yes sir actually pt. Ko chalne me hi arhe h aisa unke papa ne btaya
Arun Chaudhary
Arun Chaudhary Sir ...output jyada h ...input se ...is baat ka kya mtlab h ? N sir ..BP b low chal rha h ..n chakkar b aa rahe hain pt ko ...weakness ho gyi h
Rakesh Biswas
Rakesh Biswas Unko shyad lasix diya hoga gharwalon ne. Output agar input se zyada ho to sharir ka pani (edema) sukh jata hai. Isliye unke ghar walon ne lasix diya hai. Thoda pani to garmi ke wajah se bhi nikal gayi hogi. Arun
Like · Reply · 1 · April 14 at 9:07pm
Rakesh Biswas
Rakesh Biswas Arun kya apko pata hai humare sharir ka kitna pratishad pani hai?
Arun Chaudhary
Arun Chaudhary 78% sir ....n unhone lasix b ni diya h aaj to ...
Rakesh Biswas
Rakesh Biswas Please supplement his fluid intake to make it at least 800 ml more than yesterday's output Arun
Arun Chaudhary
Arun Chaudhary Okkkk sure sir ...kra dete hain
Arun Chaudhary
Arun Chaudhary Sir ...actually night me to ...intake only 500 ml ..h ..n output 1500 ml ..h sir ...ye sb kese ho rha h. ..
Rakesh Biswas
Rakesh Biswas Arun always look at the 24 hour input-output not just night or day. Jyoti let us know what is the total I/O chart from 8:00 AM yesterday to 8:00 AM today.
Rakesh Biswas
Rakesh Biswas Dr Swagata, Dr Bharati if you happen to be visiting LNMCH today please do also check out this patient and let us know your impression here. Jyoti will also get in touch with you regarding this patient. I hope she has prepared the online-record of your ca-colon patient? Jyoti please share it's link here.
Arti Jat
Arti Jat Sir pt. Ka out put kl night me jyada tha 
Unka kehna h ki tab.aldactone lene se jyada hota h. Aj morning me hi Di h to ab normal h..sir tab. Continue leni h ya abi off kr de
Rakesh Biswas
Rakesh Biswas Arti inka kalka 24 hours ka (parson 8:00 AM se aaj 8:00 AM) ka output kitna hai please batayenge?
Arti Jat
Arti Jat Kl ka intake1200ml and output 1300ml
Rakesh Biswas
Rakesh Biswas Arti yeh ek summary jaisa lag raha hai par is input-output ko generally hourly ya 6 hourly calculate kiya jata hai. Shayad aur bhi koi chart hoga inke input-output calculation ka Arun?
Arti Jat
Arti Jat Morning ka intake 500ml and output 1500 ml tha 8am tak
Rakesh Biswas
Rakesh Biswas Nahi Arti kuch gadbadh hua hai calculations mein. Brother ko yahan add kar sakte ho?
Arti Jat
Arti Jat Sir yha koi bi Ni h infact brother bi Ni h
Rakesh Biswas
Rakesh Biswas Matlab koi bhi nursing staff nahi hai Arti?
Arti Jat
Arti Jat Sir vo tab. Dena h ya Ni pt. Ne li hi h abi tk
Arti Jat
Arti Jat Yes sir
Rakesh Biswas
Rakesh Biswas Haan Aldactone to de sakte ho
Arti Jat
Arti Jat 10 0`c tak the fir ab Ni h fmw me h mmw me ni
Rakesh Biswas
Rakesh Biswas Par input output calculations thoda sahi se ghar walon ko hi bol do ki woh kar len. Bharat mein nursing care ki problem hai (nurses ka dosh nahi hai) isliye kafi had tak gharwalon ko yeh sab seekhlena padhta hai. Roj 8:00 AM ko urobag khali karen aur 4 hourly note karte rahen input-output agle din 8:00 AM tak.
Arti Jat
Arti Jat Ha sir gharvalo he hi Sara note krvaya tha kl bi or aaj bi
Arun Chaudhary
Arun Chaudhary Gadhbadh ni hui h sir ...Aisa hi h ...uske addender ne ...khud calculate krke btaya h
Rakesh Biswas
Rakesh Biswas Uska matlab yeh hisaab ka break up jo normally nursing note mein hota hai woh relative ke pass hai Arun:-)
Arti Jat
Arti Jat Ha sir relative he hi note kraya tha
Rakesh Biswas
Rakesh Biswas Arti relative ke apne note ka koi image? :-)
Arun Chaudhary
Arun Chaudhary Sir ...vo b count krte hain ...acc. To you sir ...hmne unke attender ko sikha diya h ...nursing vaale agar dhyaan na de paayen to ...vo to de len
Arti Jat
Arti Jat Sir ye aaj morning 7 am se start h kl morning 7bje tak ka note krene keh diya h
Arti Jat
Arti Jat I have go my room its urgent my brother suffering weakness and continue doing vomiting
Arti Jat
Arti Jat Sir can I..?
Rakesh Biswas
Rakesh Biswas Sure Arti. Hope your brother recovers soon. If you need any help bring him to the hospital and we can ask the CMO to assess and manege his problems together.
Arti Jat
Arti Jat Thanks sir
Rakesh Biswas
Rakesh Biswas I guess he is in Bed 16 Arun? Please get the details of what is happening from the nursing staff and share here.
Arun Chaudhary
Arun Chaudhary Yes sir ...he is on bed 16 ...
Arun Chaudhary
Arun Chaudhary Total output of day - 15-4-2016 

7 am to 8 pm - 600 ml
...See More
Arun Chaudhary
Arun Chaudhary Today's notes - 

C/O - abdomen distended ...urine obstruction at the time of motion ..both foot swelling ..weakness .
...See More
Arun Chaudhary
Arun Chaudhary Total intake of night - 8 pm to 7 am - 550 ml 

Total output of night - 8 pm to 7 am - 800 ml 


Total output of 24 hours - 1400 ml

Total intake of 24 hours - 2,485 ml 
= 2 ltr. 485 ml
Rakesh Biswas
Rakesh Biswas Jitna bhi excess pani hai I-O woh aaj Jyoti ko nikaalna hoga.
Jyoti Sunder Tripathi
Jyoti Sunder Tripathi Swelling in both feet....
Water intake..__300ml
Urine output__100ml
Rakesh Biswas
Rakesh Biswas His leg swelling seems to have redueed JyotiArun