Clinical Reference Updates – January 2012 Summary for Medscape App for Android™

• 487 diseases & conditions updated
• 114 drug monographs updated
• 4 new drug monographs added

Featured Content of the Month – Heart Failure

This month we bring you an expanded collection of over 30 Heart Failure topics that have been updated with the most recent developments from medical literature and guideline recommendations from the American Heart Association, the New York Heart Association, and the European Society of Cardiology.

Comprehensive coverage on Heart Failure, including:

Heart Failure – includes the latest guidelines from the ACCF/AHA, NYHA, and ESC, as well as a greatly expanded multimedia library of clinical images and videos

Echocardiography – discusses the technical aspects of 2-D and Doppler echocardiography and provides an overview of equipment and patient preparation

Transvenous Cardiac Pacing - provides details on obtaining venous access, a technique for placement of the pacing lead, and complications that may occur

Permanent Pacemaker Insertion – offers information on devices and equipment, details on the implantation technique, and a discussion of technical considerations

New Drug Monographs

azilsartan/chlorthalidone (Edarbyclor)
New drug combination of an angiotensin II receptor blocker and thiazide-like diuretic indicated for treatment of hypertension.

glucarpidase (Voraxaze)
New carboxypeptidase enzyme indicated for toxic plasma methotrexate concentrations in patients with delayed methotrexate clearance due to impaired renal function.

Drug Monograph Updates

brentuximab (Adcetris)
A new black box warning was added that describes cases of progressive multifocal leukoencephalopathy, a rare but serious brain infection that can result in death.

C1 inhibitor human (Berinert)
Expanded indication includes treatment of acute attacks for laryngeal hereditary angioedema.

pneumococcal vaccine 13-valent (Prevnar 13)
New indication for prevention of pneumonia caused by Streptococcus pneumoniae in adults aged 50 years or older.

raltegravir (Isentress)
New pediatric indication for HIV-1 infection in children aged 2 years or older.

Fentanyl transmucosal (Subsys)
New sublingual spray indicated for breakthrough cancer pain.

Practice Changing Updates

Our app is continually being updated with new FDA drug approvals, the latest clinical updates from medical literature and current guidelines to help you stay informed and make the best decisions in the treatment of your patients. Here are this month’s featured updates:

Bacterial Pneumonia – Prevnar 13, a pneumococcal 13-valent conjugate vaccine, has been approved by the U.S. Food and Drug Administration for people aged 50 years and older to prevent pneumonia and invasive disease caused by the bacterium, Streptococcus pneumoniae.

Human Papillomavirus – The CDC now recommends the quadrivalent HPV vaccine (Gardasil) for routine use in boys aged 11 or 12 years. Current recommendations advise vaccination for males aged 13-21 years who have not been vaccinated previously or who have not completed the 3-dose series.

“The thing that is missing is getting the people with the domain expertise aligned with the people with technological know-how to turn ideas into branded services,””

I think these comments ring true for many of us that realize the disconnect between the people designing and building products for healthcare, and those actually using them. I can attest to the fact that it exists in many aspects of pharmacy automation and technology where things have a way of being forced down your throat. It becomes a game of which product is the “least bad”. It’s called settling for something, and it never really makes anyone happy. That’s why we’ve seen so many homegrown systems in pharmacies over the years.

There once was time when terrible usability at least meant great functionality. Unfortunately many companies have chosen to improve the usability at the expense of the functionality, which ultimately leads to a crappy product. I’ve experienced this many times during my career, especially with pharmacy information systems where improved UI’s have often resulted in poor performance, more mouse clicks and frustration.

Do the industry a favor and ask the end users what they need, instead of giving them what you think they want.

According to Tablets Planet the “Latitude ST tablet features a Intel Atom processor, Windows 7, Microsoft Bitlocker, Kensington lock, USB port, SD card slot, HDMI port, and a LCD that features finger multi-touch and a stylus for input, and there are also front and rear-facing cameras for video conferencing (front) and taking photos (rear).”

In addition the Latitude ST claims an 8 hour battery life. This is in line with the battery life claims of the Samsung Series 7 tablet.

Now if I could just get Samsung or Dell to develop a docking solution similar to the Asus Transformer we’d have something.

In this case it’s ASHP’s Interactive Handbook on Injectable Drugs: IV Decision Support by Lawrence A. Trissel. Every pharmacist working in a hospital pharmacy knows about this reference. And if they don’t then they have a big problem because it’s only one of the most definitive reference sources for IV compatibility. Over the course of my career it’s simply been know as “the Trissel’s”. (kind of like “the Talyst”…just sayin’ – private joke people)

There’s a link in the ASHP web store leading to a “getting started video”, but I couldn’t get the video to run. Little bit of a fail. Perhaps ASHP’s never heard of YouTube. Who knows.

Link to Android version is here.

Link to iPad version in iTues store is here.

You can find more information here.

Lexicomp’s I.V. Compatibility module is now available for your Lexicomp On-Hand subscription for Android™! By following the update instructions below, you can add this module to your existing Lexicomp On-Hand subscription. There is no additional charge for this enhancement.

The I.V. Compatibility module allows you to review compatibility and stability information for hundreds of parenteral medications and fluids. This module is based on information from the King® Guide to Parenteral Admixtures®. Thousands of clinicians are already using Lexicomp’s I.V. Compatibility module every day – now you can access this vital information on your Android smartphone or tablet as well.

To update your subscription to include I.V. Compatibility, follow these instructions:
Ensure you have a strong Wi-Fi or cellular connection.
On your Android device, tap the Market icon and search for Lexicomp.
Select Lexicomp and tap Update. When the warning appears, tap Accept & Download.
When the application is installed, tap the Lexicomp icon to access your software.

In my mind the ASUS Eee Slate EP121 (who comes up with these names?) is currently the best tablet PC slate on the market. I’ve spent quite a bit of time messing around with it at the Microsoft Retail Store at Bellevue Square in Washington. The employees in there must think I’m some kind of stalker.

As far as the EP121 goes the inking is great, the touchscreen responsive, it’s fast, it’s the perfect size and it just “feels right” in my hands. So what’s the problem? The battery life is terrible? The information on the tablet states that the battery life is less than 3 hours. Online reviews have it at about 2 hours. That’s ridiculously bad in this day of hi-tech.

I looked hard at the Motion Computing CL900, but just don’t think it has enough muscle for me. It’s a bit slow and clunky. That’s a bummer as on the surface the CL900 looks like the perfect device.

While rummaging around the Motion Computing website for information on the CL900 I stumbled across an old friend, the Motion J3500. I’ve used it’s predecessor, the J3400 before and it was a great machine. I found the J3400 to be a good mix of functionality, toughness and battery life. With upgrades to the hard drive, processor and display the J3500 may just be the best option currently available, which says something about the tablet market; the J3500 is over a year old.

To the best of my knowledge the next twelve months will bring tablets of all shapes, sizes and OS flavors to the market. I’ve seen information on tablets with screen sizes ranging from 7-inches to just over 10-inches, and operating systems including Android, Windows 7 (8?), WebOS, BlackBerry, and of course iOS. Did I miss any? It’s possible that I did as I’ve seen a few others thrown in the mix over the past several months, but I believe these constitute the bulk of what we’ll see.

With that said, what impact do I think these devices will have on pharmacy practice? That’s a good question. Because I’m a tablet enthusiast I’d like to think they will revolutionize pharmacy practice as we know it, but in reality it probably won’t make much difference at all. Why? Site back and I’ll tell you.

I spent quite a bit of time pondering the use of tablet PC’s in pharmacy well over a year ago. After painstaking deliberation I concluded that “the evaluation and implementation of tablet PCs into pharmacy workflow is a daunting task and several questions must be answered and barriers addressed prior to moving forward. I believe it’s worth the effort as the tablet PC offers unparalleled access to patient data and drug information resources in a mobile platform. It is clearly a tool worth further investigation.” I took my own advice and spent the better part of a year investigating ways to better utilize tablets in pharmacy practice. And here’s what I found out:

1. Pharmacists are painfully slow at adopting new technology. Paper and pen appear to be the technology of choice for many pharmacists. This is incredibly frustrating. Nurses and physicians are quicker to accept new technology. Why? I have no idea.
2. Pharmacists, in general, are not the most tech savvy bunch. I can’t tell you the number of ridiculous questions I got regarding the use of tablets. Pharmacist: “Hey Jerry, how come the screen is blank?” Me: “Umm, because it’s turned off?” Pharmacist: “Oh.”
3. Pharmacists, in general, don’t care what technology they use as long as they can do “clinical work”. Unfortunately this equates to rarely trying anything new.
4. Not everyone takes care of equipment like they should. We utilized 4 tablet PCs and 6 iPads over the course of 18 months. They took a lot of abuse. Failure to charge the device was the biggest issue though.
5. Tablet hardware just isn’t quite ready for prime-time use in the pharmacy.
6. Pharmacy applications are not designed for use on a small screen. This caused more issues than you can imagine.
7. The pharmacists loved the iPad…until they started using it. The touchscreen is great, but pharmacists wanted to use a pen. You can use a stylus on the iPad, but they aren’t very good. Lack of native applications or applications optimized to run on the iPad was also problematic. Android, WebOS and BlackBerry will have similar issues (see #8 below)
8. Most healthcare applications are designed for use on PCs. Yeah, a virtual desktop works for use on non-PC based tablets, but it’s not optimal. It’s like looking at the moon through a window. Sure, you can see it, but it looks a lot better if you just walk outside. Many pharmacists found it difficult to work in a virtual environment; not to be confused with a cloud environment.

Some things that need to be improved to make tablets more usable for pharmacists:

1. A hybrid tablet that allows full desktop functionality while docked, but uses a smaller, optimized OS when in tablet mode. This is more important than you might think. Pharmacists don’t need a bloated desktop when they’re on the go, but they do need a core set of functions.
2. The Motorola Atrix 4G is a great concept that should be explored further. I’ve thought about this for a long time. I’d like to see some changes to the Atrix Lapdock though. Instead of having the Atrix dock on the back of the keyboard I’d like to see it slide into the side of the monitor. Kind of like a PCMCIA card. Then take the Lapdock design one step further and have the monitor portion of the dock come away from the keyboard. Instant tablet.
3. Tablets need to replace pen and paper. Yep, it really is that simple; small, light, easy to carry, quick on/off, ability to take notes on the screen with a pen, note storage and easy sharing, etc. Until tablets are as easy to use as legal pads, pharmacists will be hesitant to adopt.
4. Technology ecosystems. We’re starting to see this already with the WebOS, Android, Windows and iOS. The ability to utilize a host of devices across a single platform is advantageous. I’m interested in what HP is doing with the WebOS on the desktop. I look forward to seeing how this works across the full spectrum of desktop –> tablet –> smartphone. Microsoft had the chance of a lifetime to develop an incredible ecosystem, but somehow let it slip past them. Just sayin’. Note: don’t you find it odd that we’ve gone from a single ecosystem, i.e. Windows, to a completely fragmented group of ecosystems? I’m not sure if that’s a good thing or not. The one positive is that it will force adoption of cross-platform applications and the cloud model. I remember talking about the need for cross-platform development 15 years ago. I was talking about Linux and Windows at the time, but that’s beside the point. People, including my brother openly scoffed at me. And why shouldn’t they have, I was just a dumb pharmacist after all; what the heck did I know about software engineering. Now here we are in a position where cross-platform development is important. I feel somewhat vindicated. Dorry, I digress.
5. Investment in cloud based solutions. As mentioned above, the number of new operating systems in use today makes this a must.
6. Improved hardware:
   1. Battery life needs to be improved to allow more than 24 hours of continuous use.
   2. Optimal screen size needs to be studied. I’m not certain that 7-10-inch screens are the best option. I’d like to see at least one vendor experiment with 11,12,13-inch screens. Think about this, typical notes are written on paper that is 8.5 x 11 inches. Wouldn’t that be an optimal size for a tablet? Not sure, but it’s worth a look. Note: ProLink makes a tablet with an 11.6-inch screen, but I haven’t heard much about it.
   3. Wireless HD video out. This is important for viewing x-rays and other images.
   4. Support for Flash. Yeah, yeah, Apple, iOs, blah, blah, blah. Look, until the internet in its entirety stops using Flash you need to support it. Period. Remember, healthcare IT is at least five years behind the consumer market.
7. Software designed to work on multiple platforms. Healthcare is definitely Windows centric. Unless Microsoft takes over the world and eliminates their competition in the next 18 months things will have to change to support all the new OS ecosystems. *cough* cloud
8. Option for pen driven or touch interface at the same time. Pen is king in this environment, but using your finger to navigate quickly is awfully convenient at times. “Pinch-to-zoom” is also important for viewing images.
9. Ability to seamlessly move documents back and forth and quickly share information. Hmm, sounds like that whole cloud thing again.
10. The ability to keep information safe even when your tablet is utterly destroyed. See Google Chrome Notebook video below to get the gist of what I’m saying.
11. Better enterprise integration. Let’s face it, a tablet shouldn’t require special treatment. Any healthcare system should be able to purchase one and have it fully integrated in a matter of minutes.

Ultimately I think tablets will see significant growth in healthcare over the next several years, but I don’t expect to see the same growth of tablet use in pharmacy practice. While a tablet seems like the perfect device for a pharmacist at the bedside, the response from pharmacy practitioners hasn’t been great. As for me, I will continue to pursue mobile technology, especially tablets simply because I find them interesting.