December 1999 Bulletin

AAOS plans 'just in time' education

Goal is to have entire curriculum online and available on hand held PCs

Surgery is scheduled for 7 a.m. tomorrow, and you find yourself wishing you'd been able to fit that course on the latest operative technique into your schedule. But it's too late now, right? No. Within seconds, you're learning the new operative method online, complete with video and current references, all at your fingertips.

Sound too good to be true? While the above scenario won't play out this century, "just-in-time" education in the cyber-classroom is likely to be a reality by the early 2000s.

A pilot program now being developed by the Academy will allow orthopaedic surgeons to go on-line to access immediate information on operative techniques and different procedures.

"Ultimately, our goal will be to have an entire curriculum of just-in-time orthopaedic surgery online, so that clinicians can use hand-held computers to access information," says Richard Gelberman, MD, chair of the Academy's Task Force 2005. "Whether at the bedside or the emergency room, they'll be able to access information on precisely the clinical problems with which they are confronted, be that operative or nonoperative. Our plan in developing this program will be to update the procedures regularly, perhaps on a six-month interval, replacing older procedures with new procedures that are proven to be efficacious."

Some 250 physicians are already using this "just-in-time" learning technology at Michigan State University the University of Virginia and the University of Missouri. The newly-developed "InfoRetriever"-a software program that's loaded with information on prescribing drugs, diagnosing patients, medical literature and case studies, while remaining compact enough to run on a palm-size PC-is now up and running at the three universities.

InfoRetriever quantifies the advantages of different treatment strategies, clarifies test results, calculates drug dosages and summarizes current research findings on a wide range of family care. Unlike Medline-a database that includes 11 million articles-InfoRetriever confines itself strictly to patient care.

The software program grew out of a project that Mark Ebell, MD, undertook at Michigan State University in 1994. Along with several colleagues, Dr. Ebell pored over 80 medical journals each month, summarizing clinically important findings for The Journal of Family Practice feature, POEMS (Patient Oriented Evidence That Matters).

"We look for articles that deal with primary care problems that use patient-oriented outcomes," Dr. Ebell says, "such as symptom reduction and improvement, quality of life improvement, reduction in mortality, morbidity-important things that patients and physicians would care about. We also try to identify things that would change the way we currently practice."

The group was already putting this growing base of information onto a database, but they wanted to bring the information to the point of care on a hand-held computer. Dr. Ebell, who had been writing software for years, went to work and the InfoRetriever was conceived. With a state of Michigan grant, Michigan State University purchased 100 palm-size PCs, installed InfoRetriever and put them to use in classes and local clinics.

InfoRetriever now includes all of the POEMS digests, along with hundreds gleaned from other reliable sources. In addition, it contains more than 320 abstracts of systematic reviews from the Cochrane Database; a calculator for clinical diagnosis using the history and physical exam; a diagnostic test calculator; summaries and evidence tables from key evidence-based practice guidelines; and a selection of validated clinical prediction rules to help physicians diagnose chest pain, pneumonia, sore throat and other common conditions. The database is updated every three months.

"The key is the time it saves the busy physician," Dr. Ebell says. "If I have a question, it's right there. I don't have to go to the library."

For instance, the journal Neurology published a study indicating that riboflavin could relieve migraine headaches. Primary care physicians typically don't read Neurology, but with InfoRetriever, they punch in "migraine" and immediately receive a summary of the study.

And the program makes it easier to apply the results of research and to individualize care to a patient's needs, Dr. Ebell says.

"If a patient comes in with a sore throat, you have to determine if there is a strep infection," Ebell says. "Ordering these tests could take days, but if I can enter the patient's information into the computer, the program can help determine the patient's risk of strep."

Although in use for just a few months, the InfoRetriever has been very well-received by the family physicians, internists, obstetrics-gynecologists and emergency room physicians currently putting it to use, according to Dr. Ebell.

"Our goal in orthopaedics would be similar to the InfoRetriever project," Dr. Gelberman says. "That immediacy is what we're looking for."

A "just-in-time learning" pilot program is now in the planning stages, and could be online on the Academy's web site by early spring, says Joseph D. Zuckerman, MD, chair of the Council on Education.

"Say you want to review a specific procedure, for example, rotator cuff repair," Dr. Zuckerman says. "What we envision is that you'll click on the Academy web site, click on "just-in-time learning" and you'll receive immediate, succinct information about the indications, procedures, video, some indication of the postoperative course, as well as links to other learning opportunities, such as other articles. So you can spend just 10 minutes, or spend 30 minutes to an hour, at home or in your office, depending upon your needs."

As fellows become increasingly computer-literate, and as more applications become available online, Dr. Gelberman says, "the opportunity to have education provided-just when someone needs it, on the precise subject they're interested in, in small segments-will be very desirable."


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