更好的決策 更佳的照護 Renewal Account Manager Taiwan 吳倫愷 0937 650 447 更好的決策 更佳的照護 Welcome. I’m xxx from UpToDate and I’m here today to discuss how UpToDate and Clinical Decision Support will help your clinicians and your organization improve outcomes, drive quality and efficiency, and make the best decisions at the point of care. By the end of this presentation you will understand the benefits that a clinical decision support tool can bring to (INSERT Organization name) and to your patients.   Renewal Account Manager Taiwan 吳倫愷 0937 650 447 Eric.Wu@wolterskluwer.com

UpToDate是什麼？ UpToDate®是唯一由醫生撰寫，以證據為基礎的臨床決策支持工具，它幫助醫護人員改進醫療的成果，帮助提高質量和效率，並在醫療現場做出最好的決定。 回答臨床的問題 獲取最新臨床知識 改善病人照護 For those unfamiliar with UpToDate: it is an online clinical decision support system, created by doctors for doctors/clinicians. In this presentation, I will share information on UpToDate’s positive impact on health care, how it works, and what makes it unique. Also, the service is widely accepted and used worldwide. As a result, UpToDate celebrated its twentieth anniversary in 2012.

實踐實證醫學的挑戰 醫學文獻隨時更新,難以將知識維持在最新狀況 缺乏解釋和運用最新醫學研究的能力 隨著時間的推移, 保持知識的挑戰 透過持續醫學教育獲取新知的困難 時間有限, 評閱文獻有所困難

為什麼在醫療現場使用預評過的臨床決策支持工具? 可供檢索、電子形式的醫學文獻（如MEDLINE）廣泛提供給臨床醫生使用。然而，大多數都不能夠在醫療現場(point of care)幫助臨床醫生回答問題。 臨床醫生往往需要多個訊息來源進行篩選，將之萃取出成為一個答案後，他們才能據此採取行動。 臨床決策支持工具 = Clinical Decision Support (CDS)

Haynes 6S Pyramid Systems Summaries Synopses of Syntheses Syntheses Synopses of Studies Studies Computerized Decision Support Systems UpToDate Evidence-based Summaries UpToDate Evidence-based journals abstracts ACP Journal Systematic Reviews Cochrane Library Systems are decision support systems that link individual patient records to the best evidence about their conditions.  These are rare at this time, but you may find rudimentary systems at some hospitals. Summaries provide critically appraised, concise information on all aspects of patient management and derive their information from the best evidence found in the lower “S” levels.  The Brickell library subscribes to several summary type resources.  Synopses are critically appraised summaries of individual trials or systematic reviews.   Synopses of systematic reviews make up the 3rd level and synopses of individual studies make up the 5th level.  EVMS subscribes to one of the best examples of this type of database. Syntheses are systematic reviews of individual trials.  Most systematic reviews address treatment or prevention; but the number of systematic reviews answering other types of clinical questions – e.g., diagnosis, etiology, and prognosis – is growing. Studies are the original trials or studies – i.e., the primary literature.  You must critically appraise this evidence yourself before deciding whether it will be helpful for your patients.  Some of the primary research databases licensed by EVMS include http://blogs.evms.edu/BrickellLibrary/?p=31 Evidence-based journal Medline/PubMed Brian Haynes. The 6S evolution of information services for evidence-based healthcare decisions

UpToDate提供實踐臨床醫學的新方法 Practice Changing UpDates CME/CPD0 10,000+ 27,000+ 臨床專文 圖表 5,200+ 140+ 藥物資訊 醫學計算工具 1,500+ With one click, UpToDate offers a wealth of resources. UpToDate covers 20 specialties. We recently added Psychiatry (August 2012). We are currently developing Dermatology and Palliative Care specialties. We offer clinicians over 9,500 topics plus a database of over 5,100 drug monographs. We have over 25,000 graphics and over 347,000 links to evidence, including full text studies. Also, your doctors have access to Practice Changing Updates which let your clinicians know when the evidence has reached a point suggesting they should change their usual clinical practice. We also offer 1,000 patient topics written by the same authors and editors who develop our clinical content so you can be sure your patient is receiving information in line with the information our clinicians are referencing. 380,000+ 病患訊息 證據連結 22 6,000+ 專科 醫師作者/編輯

嚴謹的編輯流程 UpToDate 編輯過程 新的臨床研究出版 我們的作者與多個專業學科的編輯群共同創建或更新專題 且會影響臨床決策 全球臨床醫生最新的專題 專題內容由作者與多個專業學科的編輯群共識而成 專題是由同儕審查 編輯群審查分級的建議 Our physician-editors specialize in evaluation of the evidence, clinical epidemiology, biostatistics and and evidence- based medicine. They also specialize in the medical area they edit. UpToDate is evidence-based. We work very closely with Dr. Gordon Guyatt, who is world-renowned for his expertise in evidence-based medicine. He is actually the physician who coined the term, “evidence-based medicine.” Dr. Guyatt comes to our Boston-area offices every 6 weeks and conducts rigorous training with our physician-editors in evidence-based medicine and grading. We developed our grading system with Dr. Guyatt. Our physician editors grade both the strength of our recommendations and the body of the evidence behind those recommendations.

超過60篇 CDS如何在醫療點改善決策並且促進醫療成果? 研究指出使用UpToDate帶來的助益 更快地解決問題 改善決策 促進醫療成果 UpToDate是最被廣泛研究的醫療點臨床決策支持工具。到目前為止，已經有超過60項研究指出UpToDate能夠: There have been over 30 independent studies conducted on UpToDate. 更快地解決問題 改善決策 促進醫療成果 We invite you to review the study data yourself: http://www.uptodate.com/home/research

37% UpToDate改善臨床決策 新加坡國立大學附設醫院的研究人員報告在病房裡使用 UpToDate可以改變三分之一以上的臨床決策 Research done at individual hospitals reinforces the findings from the wider Harvard Outcomes and Solucient studies. In a study published in the Singapore Medical Journal, researchers at Singapore’s National University Hospital found that use of UpToDate led to changes in investigations, diagnosis or management 37% of the time. In other words, patient management decisions were changed more than one-third of the time when UpToDate was consulted. The body of research on UpToDate all supports the premise that UpToDate has measurable benefits and positively impacts patient outcomes. Phua J, See KC, Khalizah HJ, et al. Utility of the electronic information resource UpToDate for clinical decision-making at bedside rounds. Singapore Med J 2012; 53:116.

庫克郡公立醫院 Cook County Hospital, Chicago, IL 臨床醫師需要制定更好決策的協助 庫克郡公立醫院 Cook County Hospital, Chicago, IL 測試：隨機抽取146例住院患者進行測試，醫師使用臨床知識支持系統的前後，關鍵決策的變化 結果：主治醫師改變18％的病人治療決策 見解：UpToDate驅使醫療決策發生改變1 First, let’s look at the impact of using clinical decision support at the point of care. In a study conducted at Cook County Hospital, Chicago, the study’s authors examined the impact of evidence-based knowledge on attending physicians’ treatment decisions for hospitalized patients. Before being provided information, most attending physicians believed that they had made evidence-based decisions. When presented with evidence-based knowledge (provided primarily from UpToDate) - physicians reported that they would change their treatment decisions for 18% of their patients. (Study Information: Random sample of 146 inpatients cared for by 33 internal medicine attending physicians at Cook County Hospital, Chicago. Study by Hospital of Cook County Department of Medicine and Rush Medical College in Chicago.) 1Lucas, BP. The impact of evidence on Physicians’ inpatient treatment decisions J Gen Intern Med 2004; 19:402.

更好的決策，提高質量和效率 大多數的決策改變改善病人照護 很多決定可能會縮短住院天數 有些能夠阻止不良事件發生 問題 原始決策 新的決策 可能的影響 動靜脈移植物喪失功能 建立暫時性血管通路 纖維蛋白溶解療法 恢复移植物的功能並免採用新 手術 重度不穩定高血壓 地爾硫卓 停服地爾硫卓加服阿替洛爾 改善血壓控制 社區感染性肺炎 靜脈抗生素 口服抗生素 避免住院治療 舒張性心臟衰竭 呋喃苯胺酸，異山梨醇，肼苯哒嗪 停止肼苯哒嗪，加服阿替洛爾 改善症状控制 不能手術的肝細胞癌，伴有腹水 經肝動脈化療栓塞術 僅採用臨終關懷 避免產生併發症 降低成本 改善症狀控制 Here are some of the management decision changes that doctors made after consulting UpToDate at Cooke County Hospital, Chicago. The study’s authors determined that most changed decisions improved patient care. The study authors looked at the number of patients admitted annually to Cooke County Hospital and calculated that routinely using an evidence-based clinical knowledge resource would improve care for 2,700 of their patients annually. UpToDate was the overwhelmingly preferred evidence-based knowledge resource in this study.

Solucient1研究UpToDate對住院時間，患者併發症和患者安全的影響2 顯著縮短住院時間 顯著降低不良醫療結果 Speaker Notes - Solucient compared hospitals with and without access to UpToDate, and they found that hospitals with UpToDate had significantly shorter lengths of stay (.167 days per discharge), lower complication rates, and better patient safety outcomes than hospitals without UpToDate. They also adjusted for hospital size, type (teaching versus non-teaching), and location. Solucient then looked at whether the amount of usage of UpToDate had any impact on these measures and what they found was… Significantly shortens length of stay Significantly lowers complication rates Significantly lowers adverse outcome rates   顯著降低併發症的發生率 Solucient maintains the nation's largest healthcare database, comprised of more than 26 million discharges per year from 2,900 hospitals. Bonis PA. Association of a clinical knowledge support system with improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the US. Int J Med Inform 2008; 77:745.

UpToDate的使用量增加帶來質量指標的改善 改善風險的比率 Speaker Notes - The more that UpToDate was used, the better the improvement in patient safety, mortality, complications, and also in length of stay.   The graph’s x-axis shows the number of “hits” or the number of UpToDate searches. If you follow the graph you’ll see that as use of UpToDate increased in a healthcare system, there was a corresponding degree of improvement in all of these key performance criteria—and to a significant degree for patient safety, complications, and length of stay. UpToDate每周的使用量 併發症 患者安全 住院天數 UpToDate 的使用與併發症發生, 死亡率, 病人安全的對應統計 Bonis PA. Association of a clinical knowledge support system with improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the United States. Int J Med Inform 2008; 77:745.

哈佛大學的研究人員發現UpToDate與改進醫療結果的關聯 提高醫院醫療質量 根據醫院品質聯盟的評價指標每種病症都獲得更好的質量評分 縮短住院時間 每年減少372,000 天住院時間 降低死亡率 三年內挽救超過 11,500條生命 Speaker Notes - Researchers at Harvard University then conducted the same type of study, but subjected the study to much stricter methodological controls. And what they found was a confirmation of the Solucient study and additional benefits. Researchers at Harvard University found that use of UpToDate over a three-year period was associated with statistically significant, improved quality on every condition on the Hospital Quality Alliance Metrics, lower lengths of stay, and an additional benefit of lower mortality rates for three medical conditions. This would have resulted in 372,000 hospital days saved per year and 11,500 lives saved every 3 years.   **Additional information on the study that you can share in your presentation as needed: This was a retrospective study using data from 3,322 hospitals in the United States (nationwide study of all hospitals) over a three-year period. It compared the outcomes between those that adopted UpToDate (1,017 hospitals) and those that did not (2,305 hospitals) using strict methodological controls. Four factors that lend confidence that the results were not due to confounding: Effects were consistent across measures that are not highly correlated with each other. The benefits persisted even controlling for other characteristics associated with adoption of UpToDate. The effects were prominent for small, non-teaching hospitals. There was a dose-response relationship of duration of use among UpToDate hospitals. The conditions on the Hospital Quality Alliance Metrics include: Acute myocardial infarction Congestive heart failure Gastrointestinal hemorrhage Pneumonia Stroke Hip fracture Note on how to put this study in the context of the broader body of research on UpToDate: This confirms what doctors have been telling us for years, that use of UpToDate changes their clinical decisions and impacts the quality of care they provide. This is one of over thirty studies that have shown that UpToDate is associated with improved care, is the most trusted and used resource, changes clinical decisions and is important to medical education. No other knowledge resource has been associated with improved outcomes. Isaac T, Zheng J, Jha A. Use of UpToDate and outcomes in US hospitals. J Hosp Med 2012; 7:85.

% 的用户說 UpToDate幫助他們在回答臨床問題上節省了時間 Doctors are able to answer their clinical questions with UpToDate; moreover, they are able to answer them quickly. In fact, doctors who consult UpToDate for clinical answers report that they are able to answer 90% of their questions with UpToDate. As mentioned earlier, lack of time and inability to sift through the high volume of medical literature are major obstacles to answering clinical questions. UpToDate helps doctors overcome these obstacles. % 的用户說 UpToDate幫助他們在回答臨床問題上節省了時間 14

Evidence Grading 實證等級 RECOMMENDATION GRADES 醫囑的強度 (診療建議的強度) Grade 1 1 級推薦 Strong Recommendation 強建議 Benefits clearly outweigh the risks and burdens (or vice versa) for most, if not all, patients “We recommend…” Grade 2 2 級推薦 Weaker Recommendation 弱建議 Benefits and risks closely balanced and/or uncertain “We suggest …” EVIDENCE GRADES 實證的品質 (證據的強度) Grade A A 級證據 High Quality Evidence 高質量證據 Consistent evidence from randomized trials, or overwhelming evidence of some other form Grade B B 級證據 Moderate Quality Evidence 中質量證據 Evidence from randomized trials with important limitations, or very strong evidence of some other form Grade C C 級證據 Low Quality Evidence 低質量證據 Evidence from observational studies, unsystematic clinical observations, or from randomized trials with serious flaws 15

有關UpToDate Anywhere 現在, 您不再受限只能在醫院的網域內透過電腦使用 UpToDate, 只要註冊UpToDate的帳號, 隨時隨地都可以使用 。 智慧型手機、平板電腦, 只要有3G、4G或Wi-Fi訊號連上網路 , 就可以使用UpToDate。 離開醫院後, 使用家用電腦或者筆記型電腦, 網址輸入 http://www.uptodate.com/online/ , Log in帳號後就能使 用。

您現在可以透過任何行動裝置使用UpToDate的App UpToDate Anywhere provides physicians with access at the point of care, wherever that may be –at home, hospital or office. Access is available through any internet browser, through the EHR, or through the UpToDate award winning mobile app for iOS, Android and Windows 8 devices 您可以在Android、iOS、Windows 8等行動裝置系統的應用商店下載免費的UpToDate App, 使用時須要登入帳號密碼, 一個帳號最多同時在兩台行動裝置登入。下一張投影片將教您如何註冊您個人的帳號密碼。

註冊UpToDate Anywhere的帳號 首先, 在醫院網域內使用電 腦打開UpToDate, 然後點 選Log-in/Register Confirm this is log-in page

簡單的註冊流程 2. 登入 1. 註冊 如果您已經有帳號, 直接登入您的帳號。 如果您已經有帳號, 直接登入您的帳號。 輸入所有欄位, 註冊您 的帳號, 輸入完再點選 Submit Registration 下一張投影片有註冊規則說明

註冊規則 User Name需要6-50個字元, 可以輸入大小寫英文、數字、或者特殊符號例如@ # % $ & + = Password需要8-24個字元, 包括至少1個大寫英文字 母以及1個數字，您也可 以輸入特殊符號例如@ # % $ & + = 美國以外的地區不需填寫ZIP/Postal Code User Name與 Password不能相同

從應用程式商店下載UpToDate Mobile App 以iPhone為例 進入App Store 搜尋UpToDate 點擊UpToDate 點擊下載 Downloading the app is easy.

登入帳號 1. 打開UpToDate應用程式, 登入您剛剛註冊的帳號, 點選Log In 。 2. 登入後點選右上角的Agree, 同意使用規範。 3. 進入行動裝置首頁, 您會看到您的使用者名稱, 表示登入成功 。

推送通知 重要：每90天內您必須在醫院網域內使用電腦登入您的帳號, 以延展您的帳 號使用有效期, 只要您有下載App, 當您打開App時會出現提醒。

如何管理自己的行動裝置？ 1. 首先要先在電腦上登入自己的帳號。 2. 點選右上角「My Account」。

如何管理自己的行動裝置？ 3. 點選「Manage My Devices」

如何管理自己的行動裝置？ 在這畫面, 您可以管理、刪除自己的行動裝置, 未來如果換手機 或平板電腦, 可以進自己帳戶內De-activate (Logout)不再使用的 裝置。

使用繁體中文搜尋 點選Setting 點選Search Language以更改搜尋語言

使用繁體中文搜尋 3. 選擇Traditional Chinese 4. 畫面跳轉後即可輸入中文。(中文輸入一樣有建議字詞檢索)

將主題或圖片加入書籤, 方便日後閱讀 當您找到一篇合適的主題或者圖片, 但沒有時間仔細閱讀的話, 您可將感興趣的內容加入書籤, 日後就不需重新搜尋。 進入某篇主題, 點選下方的分享(此處以iPhone 為例), 再點選Add Bookmark。

將主題加入書籤, 方便日後閱讀 回到首頁, 點選Bookmarks & History即可找到您剛剛加入的內容

在專文內輸入字詞，快速找到關鍵字 進入內容之後, 點擊右下角Find in Topic, 畫面即出現搜尋列, 在 此可輸入字詞, 快速瀏覽

Thank you! Eric.Wu@wolterskluwer.com 0937 650 447 Please feel free to contact me if you wish to have further training for yourself or your colleagues.