Keeping Your Clinical Practice UpToDate™

Perhaps I have a bit of a skewed perspective because I attended medical school in the heart of Silicon Valley. Since I started my medical training in 1993, I’ve seen it on my attendings’ desktops, in call rooms, and on computers all over Stanford Hospital. Readers may disagree with me then, when I say that I have always thought it was somewhat anachronistic to name a popular computer program, distributed on CD-ROM and saved to one’s desktop, UpToDate™.

Indeed, how relevant can static electrons embedded in reflective plastic on a CD-ROM be in an age of rapidly-progressing medical research that challenges our existing clinical practice on an almost daily basis? I will admit from the outset of this review that I hold a particular bias. The technophile elitist in me has always likened UpToDate™ to the horse and buggy, or a cozy New England bed and breakfast: a quaint, if not endearing remnant of the twentieth century with questionable relevance to modern life.

What is UpToDate™?

The product literature for UpToDate™ states that it synthesizes published evidence and clinical experience in more than 15 medical specialties to provide recommendations for patient care in a fast and easy-to-use format. The company was started by a Harvard Medical School professor in 1992. Its content is maintained by a group of physician editors in collaboration with more than 3,000 expert physician authors around the world, who review research findings in more than 290 medical journals each month. The program is updated three times per year, and its database contains 60,000 pages of original peerreviewed text, 160,000 Medline abstracts, and a complete drug information database. The product is licensed by an individual subscriber for $495 (a renewal rate of $395/year). A discounted rate of $195 is available for physicians in training.

Installation: Time for a Latte and a Newspaper

I received UpToDate version 11.2 as a two-volume CD package for installation. The program is available for both PC and Macintosh computers. One thing to note: this program is large —very large. Probably not as large as the Library of Congress, but the product literature says it will take up to 1.2 GB of hard disk space for a complete installation. The entire process, including swapping CDs back and forth and completing the online program activation, took about 30 minutes. It was just about enough time to for me to read through the New York Times and have my morning latte.

Putting it to the Test

Now that the program was properly installed, I was ready to begin work. To set the mood, I put away the installation CD and popped in a Sarah Vaughn music CD for my journey back in time. To my surprise, the program would not function without the original installation CD in the drive. A review of the “Help” file on my hard drive revealed that by choosing “Standard Installation” during the install process, I would be required to keep the installation CD in my drive every time I wanted to run UpToDate™. I did find this to be a charming, if not quaint, software feature that I have not encountered since the first clumsy software protection devices requiring special plug-ins to the serial port of my VIC-20 computer in 1982.

Now up and running, sans Sarah Vaughn, I found the UpToDate™ interface to be elegant and sleek in a Google-like utilitarian way. Now for the test. I had recently completed a lengthy literature review of various outcome studies of DVT prevention following hip replacement surgery. Over the course of several days, I had gathered a plethora of papers from the primary literature using my customary online sources such as PubMed and MDConsult. What would UpToDate™ have to say on the subject? Indeed, would it even mention guidelines I found from the 6th ACCP Consensus Conference on antithrombotic therapy?

I typed “deep venous thrombosis” into the box and clicked on “Prevention” from the list of choices that returned. The CD-ROM drive began to spin, and five to six seconds later a 20- page document on prevention of DVT began to appear. This was part one of two documents on the subject. References were hyperlinked to citations from the primary literature. The document, an impressive and thorough review article, not only contained references I had already found, but additional citations and information I had previously missed during my own online literature search. Remarkable.

The CD-ROM is dead. Long Live the CD-ROM.

Indeed, a mea culpa is in order to my misjudged UpToDate™ colleagues. In all my technophile snobbery, I judged a book by its cover and not by the quality of its contents or the ease of use of its interface.

I do, however, stand by my assertion that UpToDate’s™ reliance on CD-ROM is awkward. Not only does it take several seconds to access data from the CD-ROM drive, but it ties up a valuable drive which can be used for other purposes. The advantage of the CD-ROM format, of course, is that it can be accessed in a call room, office, or clinic that does not have Internet access. This does not, however, seem to be a particularly compelling advantage in our age of wireless LANs and ubiquitous Internet connectivity.

Imagine my surprise when I learned that UpToDate™ has a website version of the CD-ROM software that provides exactly the same interface and content. One visit to the website and I was sold. The website is actually faster than running the program on your desktop because it bypasses the need to spin-up and access the CD-ROM drive every time you want to access information. The website also has “printer-friendly” formatting and automatically updates as new content is added to the program.

I learned that UpToDate™ is also available for PDA, and that this feature is included in the subscription price. Like many of my physician colleagues, I own a Palm-based PDA. However, if you do happen to be fortunate enough to own a Pocket PC-based device, you will be able to run UpToDate™ directly from your PDA. You will need to purchase additional hardware, including a 1.0 GB compact flash card to store the program.

Sometimes Quaint is Good

There is a reason why a computer program endures for more than 10 years. The quality, depth, and breadth of its content and its easy-to-use interface make UpToDate™ as relevant today as it was in 1993. In an age of information overload, UpToDate™ provides detailed and clinically-relevant reviews of medical information which ultimately improves our ability to deliver the best possible patient care. My recommendation? Definitely get the horse and buggy. ONG