Technology Report

This feature highlights some of the technological tools and applications, more commonly referred to as "apps", which facilitate better care for long-term care residents. Check back often for more! If you know of any that have been especially useful to you and your practice, please feel free to share with us.


 

DynaMed Plus App Review

by Jay Luxenberg, MD

Dr. Gieseke writes an excellent article in this issue supporting having access to clinical references available at the bedside or at least within a long term care facility. In particular, he shares his experience with UpToDate. I also subscribe to UpToDate and  like Dr. Gieseke, I have had a similarly excellent experience with it. Ever curious, I have also been using a different resource, DynaMed Plus. This has been a membership benefit from the American College of Physicians. While it is available to me for no additional cost, I have been comparing it to UpToDate. I have used the web based product and the IOS app. They also have an app for Android. 

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Genworth Cost of Care App & Website Review

by Jay Luxenberg, MD

When talking with a patient or a family member about the costs of long term care, I often want to be able to give them an accurate estimate of the relative costs of adult day care, assisted living, skilled nursing, and any other home and community based options available. I realize that these costs vary widely across the country and even within different areas of California. I find using the iPhone app or the website of Genworth’s long term care Cost of Care estimator the best resource. I recommend it when teaching geriatrics fellows or medical students doing geriatrics electives. Genworth is a long term care insurance company, and they use the information they gather about costs to make these tools very accurate. They are revised annually, and the 2016 costs have just been posted. Take a look here or try downloading the apps – the iPhone one is here. They are free. 

 
Personalized Medical Journals

by Jay Luxenberg, MD

When deciding which app to write about, I tend to look at my iPad and iPhone and see which apps I’ve migrated to more prominent positions such as my “home page” to make access easier. I noticed I have two similar apps on my iPad, Read by QxMD and docwise (with capitalization or lack thereof as the apps authors use). Both are apps that provide a customized subset of recent papers in medical and scientific journals for me to browse in an interface reminiscent of reading an illustrated magazine. I’ve been using Read by QxMD longer, but clearly I like docwise better as it has migrated to my home page and I check it almost daily. Both offer a nice selection of the journals I prefer to follow. Read by QxMD does offer more journal support, including JAMDA. Both allow me to pick topics I am interested in and particular journals, and then they produce a magazine-like interface with recent articles that I can browse. I prefer the interface of docwise, which is clean, pleasant to manipulate and relatively straight-forward to navigate. Docwise also nicely integrates medical news sources that match my stated interests, including sources like FDA Medwatch that I should keep up with. Both apps smoothly integrate with my university VPN access and my personal subscription information to allow me to download full texts as pdfs. It stores articles offline, so I can catch up on reading while on planes or away from Internet access. I have to admit to being too grumpy for much social networking, but apparently it does integrate with common social networks in case you want to share an interesting article with your Facebook friends. It’s hard for me to put a finger on why I prefer one to the other, and I do keep both on my iPad, so perhaps it would be worthwhile for you to experiment with both as well to decide which interface you like best. The price is right, as both are free. Read by QxMD is reportedly planning of adding premium features for a charge in the future, and docwise reportedly will have advertising, but for now I don’t detect any obvious commercial influence. CME2 credit is offered, and CME1 is offered after questions are answered in docwise. Read by QxMD works on the iPhone, and reportedly docwise is also working on an iPhone app. Neither is yet available on Android platforms.

I think the general concept of personalized medical journal and news reading apps is wonderful, simply by making it more likely I will read an article or two instead of playing a game. The category seems to be rapidly growing and each app has been frequently updated with new features. I think they represent another way that tablet computing is changing our practice of medicine for the better.


 
Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

Jay S. Luxenberg, MD

It seems like every decade or so we have a new iteration of the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. The last one was in 2003, and now we have a new update with a handy, dandy pocket guide and promise of a mobile app clinical tool in the near future. I think that the impact of the new criteria will be fostered by the fact that more and more of us are using electronic health records. I used the criteria to generate some reports, and found plenty of room for improvement. The latest iteration both eliminates references to archaic drugs and adds reference to many new drugs. The criteria take into account recent studies and black box warnings. For example, for antipsychotics the criteria state, "Avoid use for behavioral problems of dementia unless non-pharmacologic options have failed and patient is threat to self or others." Note that "and" – they are really saying that unless the patient is a threat to self or others, then antipsychotics should be avoided – that is a step beyond previous advice that simply said when non-pharmacologic approaches failed to eliminate the troublesome behaviors. If you haven't had a chance to review these new recommendations, please take this opportunity to download them. I am sure there will be discussion of aspects of the new recommendations at our national meetings and at the upcoming CALTCM 38th Annual Meeting.

 
UpToDate

by Jay Luxenberg, MD

I’ve been writing about apps for more than a year, yet I haven’t written about the medical app I use the most often now. I will attempt to explain why the app I use is expensive, leagues away from the mostly free apps I have been writing about. It is UpToDate.  You are likely familiar with them as a web-based resource, and in my case I have been using them for years through an institutional subscription. I have found their frequently updated reviews of clinical topics very useful, but I have not had access to their app until recently, as their institutional subscriptions do not offer access via smartphones or tablets except through the web browser while using a VPN – way too cumbersome for me to find useful under most clinical circumstances. Recently, however, I have purchased an individual subscription, which allows access via my iPhone and iPad. That is what I will discuss today.

UpToDate is a clinical decision support system, and you may have read a recent paper in the Journal of Hospital Medicine entitled “Use of UpToDate and outcomes in US hospitals”  (DOI: 10.1002/jhm.944) that indicated that hospitals that offer access to UpToDate to their clinical staff experience shorter lengths of stay, lower risk-adjusted mortality rate, and better quality performance for every condition on the Hospital Quality Alliance metrics. The apps remember your log-in info and so with minimal effort you are able to access a search function that offers very useful summaries of the most recent clinical studies and guidelines for just about every clinical situation I manage to look up. It also offers calculators, a “what’s new” feature by clinical arenas including geriatrics, and a “Practice Changing Updates” for those of us that are time challenged. Now hold on to your hat’s, kids – it keeps track of the time you spend looking stuff up, and offers AMA PRA Category 1 CME credit. It also offers AAPF CME, and credit for PAs and NPs as well. I’ve been very happy with the quality of the information presented, and haven’t noticed any nefarious influences. The iPhone is always with me, but the iPad application is just beautiful – well formatted and easy to read. You can also print off information including very useful patient information on a truly impressive range of topics. The apps utilize links, linking you to detailed drug information and references. Click on a reference and you will get detailed abstracts and a PMID that allows you to quickly find the whole article. 

Although prices vary with type and length of subscription, baseline is $499 a year, or $45 for a recurring 30-day subscription. Trainees get a discount.

I have been very happy that they offer group discounts for group practices that order 11 or more individual subscriptions together with one form of payment – that is what I am availing myself of, as I offered access to every physician and NP in our practice.  I really do find that it is worthwhile paying for access even though I get on-line access free through my university teaching affiliation.  Now you can see why I was hesitant about writing about this – after all those wonderful free apps I am confessing my affection to an expensive service. Oh well, some things in life are apparently worth a bit of hard earned money!

 
Heart Failure Trials & iLiver App Review

by Jay Luxenberg, MD

I’ve previously been concentrating on general medical apps or those specific to geriatric medicine. This article will highlight some dandy apps that are disease specific, but still very pertinent for those of us caring for elderly patients.

 

Heart Failure Trials is an app for the iPhone/iPad or android operating systems. The cost is nada, zilch, nothing – it is free! It is truly amazing – a comprehensive review of every major clinical trial of drug or device therapy for acute and chronic heart failure. It provides the reference, of course, but I appreciate the succinct summaries of the important points of the trial, the design, inclusion and exclusion criteria, size and follow-up data, primary and secondary outcomes, and best of all the associated guidelines that are based on the trial. Just click on a button and it sends you to Pubmed where you can track down the paper itself if you need it. I have to say this is one of the most elegant and easy to use apps I have used. Heart Failure Trials was designed and written by David Majure, MD MPH, a heart failure cardiologist trained at the University of California, San Francisco and The Johns Hopkins Hospital and he deserves a hearty thanks for the effort.

Another app I have been appreciating comes from Europe, and is a compendium of liver diseases with in depth information on symptoms, physical findings and signs, clinical course, diagnosis including differential diagnosis, management and therapy. It is like having an easy to search textbook on your phone. iLiver is free, and is currently only available for the iPhone. It is developed by the European Association for the Study of the Liver. Info is here: http://www.iliver.eu/  I did not have any trouble with its European origins – I couldn’t even find a reference to Mal de foie.

Please remember to share any useful medical related apps – there are so many out there that it will take a village to find and evaluate them all!

 
Medical Apps to Assist in Your Practice

by Jay Luxenberg, MD

A few months back, we highlighted some apps that aren’t specifically medical, but are incredibly useful in a medical practice. This month I’d like to talk about a few apps that actually are targeted to us.

I’m sure everyone with a smartphone, PDA (assuming PDAs are still in use at all) or tablet uses at least one and probably several apps to access news. We are all interested in what is happening in the world. As medical folk, though, we have more specific interests that are poorly served in the general news media. For example, those of us in the long-term care world in California are desperate for accurate and timely information on the state budget process and the impact of the recent cuts on various programs serving the elderly. Although the general newspapers and news sites have some of this information, it takes searching and the articles are often general rather than containing the specific information (and dare I say it – gossip) that we crave. That is where the California Healthline app comes in. California Healthline is published by the California Healthcare Foundation. California Healthline itself is a website that is updated frequently and one can follow them on Twitter or Facebook, or your favorite RSS newsreader (more on those in a future article) but I prefer their app. It’s currently available for the iPhone and iPad. It allows you to store recent news content directly on your device for offline reading, for times you are off the internet, so you can even read it on an airplane. The app is free of charge and free of advertisements. I haven’t noticed any particular evident problems with interpretation of news, but of course your mileage may vary. I hope it soon becomes available for other platforms, particularly the fast growing Android platform.

What about medical news? I’m sure we each have our favorites, and I’ll share mine. For me, it’s easy to decide which apps I use the most – they find their way to the first page on my phone and iPad. Medscape seems to always reside there. It has many functions helpful for medical use, but today I am talking about the “news” function. Medscape has a “Medscape Today” function reached by clicking on “news”, which brings you to news from several wire services as well as Medscape’s parent company, WebMD. Medscape is available for iPhone, iPad, Blackberry, and Android. Once you have it – explore the rest of the app as well. You will be amazed at all the useful information it has. There are more than 4000 clinical reference articles, available off-line. There is access to more than 2500 medical images and 150 videos. It essentially serves as a portable textbook. You can be stranded on a ski lift for 10 hours and end up knowing more medicine than your old chief of service. It also serves as an excellent drug reference, much like Epocrates. It has good coverage of herbal treatments and vitamins as well. It has a nice drug interaction checker. I am not sure why, but Epocrates is behind the times in supporting the iPad’s screen resolution, and I find myself using Medscape instead most of the time.

Speaking of Epocrates, one of the initial developers of Epocrates has a new app that I have been having fun with. It is called Doximity, and it’s available for iPhone and Android so far. It is free, and after signing up it almost magically (or perhaps symptomatic of the loss of privacy associated with a career in medicine) it finds all the folks you went to medical school and the folks you trained with in residency. Find out what specialties they chose, and where they are living. See if any have addresses in jails or prisons. You can download their contact information and set the ones you liked as “colleagues”. Add you consultant network as colleagues, and you can send them encrypted e-mail. It also let’s you look up physicians by specialty nearby or by zip code. Put “90210 plastic” in search and you will have a list of the more than 200 plastic surgeons in Beverly Hills. You can even do special searches like finding physicians that speak a certain language in a particular specialty. Telugu speaking cardiologists, anyone? It also has the phone numbers of medical students – handy for when you will be late to attending rounds. The app also finds and gives you phone numbers for your local hospitals, medical facilities and pharmacies. It starts with a map of your vicinity, and with a touch of a button you can identify all the 24-hour pharmacies and touch them to dial. For the other pharmacies it has their hours. Of course, this works for locations other than your local one as well. All-in-all, a very nice start for a relatively new app.

I’ll leave some apps to discuss in future editions of the Wave. Meanwhile, please feel free to suggest your own favorites.

 
CALTCM is Excited to Announce Our Very Own App!

by Barbara Hulz

CALTCM Members can now access exclusive resources, links, calendar events, registration forms, personal profiles, and the entire CALTCM membership directory via an exclusive app! The app is currently only available for Apple products. The Android app will be released shortly.

To download our app:
1. Visit the Apple App Store on your iPhone, iPad or iPod Touch 
2. Search for "Member Clicks" (our new database management program)
3. Download the FREE app 
4. The Organization ID is caltcm (all lower case). Please use your CALTCM username
    and password to login

The "Articles" icon will lead you to multiple resources and tools. If you would like more information, or would like to see additional content added, please contact us at info@caltcm.org.

 
New Apps Lend Helping Hand to LTC Physicians

by Jay Luxenberg, MD, CMD

As I watched group of attending physicians at work while they were admitting patients to our nursing home, I was struck by how often they were consulting their smart phones, iPads or laptops. In particular, smart phones seem to be the most commonly used resource. This year, CALTCM intends to highlight some of the technological tools, particularly “apps”, which facilitate better care for long-term care residents. As an Apple addict, I have to admit that my own familiarity is with Mac applications, iPhone and iPad apps. I’d love to hear of your own experience with other platforms.

Perhaps the best place to start when considering medical apps is a web site devoted to reviewing them. iMedicalApps.comgathers reviews from medical professionals, including medical students, and I have found it a useful tool in identifying those apps that are truly useful while eliminating lots of the junk that is out there. They are platform agnostic, so there are plenty of Android and Windows Phone app reviews as well as iOS (Apple’s operating system for phones). They periodically issue useful lists such as the top 10 free iPhone medical apps.

I also think it is very important to think about apps that are not specifically medical, but make life in long term care medicine much easier. I am a big fan of Evernote. Evernote is a program which runs on Macs, Windows, and Linux. There are versions that run on the iPhone, iPad, Blackberry, Android, and others. In fact, they tout that they are available for “nearly every computer, phone and mobile device.” What it is is a way to sync notes, pictures and sound files between your computer and your mobile device, while keeping copies “in the cloud” where you can access them from any computer you happen to be at. What good is this from a medical standpoint? Simply, I keep copies of all the state and federal regulations that we live and die by, I keep all the little tables and algorithms and lists that I find useful for differential diagnosis, etc. I keep information I need about the CCRCs and RCFEs and hospitals that I need to have handy. I keep copies of forms like the POLST, and scales like the GDS, and key papers, all as pdfs. I can then e-mail them to students or colleagues when they come up in conversation. I keep scans of my Passport and itinerary when I travel for meetings. I put in handouts, such as the pdf AMDA now uses instead of paper handouts at the national meeting. I put in the manual for the phone system at work, and “how to” instructions for tasks for our electronic health record system. I put in the manuals for my camera and all the other gadgets I use. I put in the budget categories I need in my role as an administrator. I put in ICD9 codes and E&M codes. I put in driving and bus directions to our facility from the university, so I can save time instructing students how to get there. I know of others that even record Grand Rounds on their cell phone, to play it back at their convenience. It also handles pictures, so I can snap a picture using my phone of a poster at a meeting and have it available when I get back to work.

Did I mention Shared Notebooks? Even with a free Evernote account, you can set up a notebook to share. There is a core group at our nursing home that is working on end-of-life care issues. We set up a shared notebook with shared resources like Joanne Lynn’s Sourcebook, the Handbook for Mortals, the Stanford End-of-Life Care Curriculum, a RAND Heath White Paper, POLST forms in every language available, and lots more. I share it with a limited number of coworkers, but one could also share with the whole world. Paying customers can also allow their shared notebooks to be modified by any of the people sharing it. Think how useful it would be to have policies and procedures available, or protocols for informing the physician about changes of condition, similar to the AMDA “know-it-all”™ cards, but customized per each physicians preference. How cool.

You probably get it now – I use Evernote as a portable brain. I can clip a web page or put a note into my cell phone, and using the magic of “The cloud” it will be available wherever I am. I can organize these files, and share subsets with different teams at work, or different groups of friends and family. Best of all, unless you are a particularly heavy user, it is free! Of course, I am a heavy user, but the annual price for storing huge quantities of data is very modest.

In upcoming editions of the Wave, we plan to highlight many useful apps, and I would love to hear from you if you have a particular favorite. E-mail me at: jay@luxenberg.net