Medical wikis dedicated to clinical practice: a systematic review

Combating information chaos: a case for collaborative clinical guidelines in a pandemic

The speed and scale of new information during the COVID-19 pandemic required a new approach toward developing best practices and evidence-based clinical guidance. To address this need, we produced COVIDProtocols.org, a collaborative, evidence-based, digital platform for the development and dissemination of COVID-19 clinical guidelines that has been used by over 500,000 people from 196 countries. We use a Collaborative Writing Application (CWA) to facilitate an expedited expert review process and a web platform that deploys content directly from the CWA to minimize any delays. Over 200 contributors have volunteered to create open creative-commons content that spans over 30 specialties and medical disciplines. Multiple local and national governments, hospitals, and clinics have used the site as a key resource for their own clinical guideline development. COVIDprotocols.org represents a model for efficiently launching open-access clinical guidelines during crisis situations to share expertise and combat misinformation.

Deep learning model for distinguishing novel coronavirus from other chest related infections in X-ray images

Novel Coronavirus is deadly for humans and animals. The ease of its dispersion, coupled with its tremendous capability for ailment and death in infected people, makes it a risk to society. The chest X-ray is conventional but hard to interpret radiographic test for initial diagnosis of coronavirus from other related infections. It bears a considerable amount of information on physiological and anatomical features. To extract relevant information from it can occasionally become challenging even for a professional radiologist. In this regard, deep-learning models can help in swift, accurate and reliable outcomes. Existing datasets are small and suffer from the balance issue. In this paper, we prepare a relatively larger and well-balanced dataset as compared to the available datasets. Furthermore, we analyze deep learning models, namely, AlexNet, SqueezeNet, DenseNet201, MobileNetV2 and InceptionV3 with numerous variations such as training the models from scratch, fine-tuning without pre-trained weights, fine-tuning along with updating pre-trained weights of all layers, and fine-tuning with pre-trained weights along with applying augmentation. Our results show that fine-tuning with augmentation generates best results in pre-trained models. Finally, we have made architectural adjustments in MobileNetV2 and InceptionV3 models to learn more intricate features, which are then merged in our proposed ensemble model. The performance of our model is statistically analyzed against other models using four different performance metrics with paired two-sided t-test on 5 different splits of training and test sets of our dataset. We find that it is statistically better than its competing methods for the four metrics. Thus, the computer-aided classification based on the proposed model can assist radiologists in identifying coronavirus from other related infections in chest X-rays with higher accuracy. This can help in a reliable and speedy diagnosis, thereby saving valuable lives and mitigating the adverse impact on the socioeconomics of our community.

Kontinuierliche medizinische Fortbildung in der Dermatologie für Ärzte und Studierende während der Coronavirus‐Pandemie – eine große Herausforderung

Kontinuierliche medizinische Fortbildung (Continuing Medical Education, CME) ist die wesentliche Grundlage der studentischen Lehre sowie der Aus- und Weiterbildung von Ärzten. Eine moderne und adäquate Patientenversorgung ist ohne sie nicht denkbar. Vor kurzem zwang die durch das schwere akute respiratorische Syndrom-Coronavirus 2 (SARS-CoV-2) verursachte Pandemie die gesamte medizinische Gemeinschaft, ihre Gewohnheiten bezüglich der medizinischen Fortbildung und Lehre sowie des Lernens in der Medizin zu ändern. Infolgedessen rückten über soziale Medien (Social Media) verbreitete digitale Aus-, Fortbildungs- und Lehrformate, medizinische Online-Enzyklopädien, webbasierte medizinische Lernportale und medizinische Podcasts in den Vordergrund. In diesem Beitrag geben wir einen Überblick zu aktuelle Konzepten in der medizinischen Online-Fortbildung, unter besonderer Berücksichtigung der Dermatologie.

Clinical indicators for common paediatric conditions: Processes, provenance and products of the CareTrack Kids study

BACKGROUND

In order to determine the extent to which care delivered to children is appropriate (in line with evidence-based care and/or clinical practice guidelines (CPGs)) in Australia, we developed a set of clinical indicators for 21 common paediatric medical conditions for use across a range of primary, secondary and tertiary healthcare practice facilities.

METHODS

Clinical indicators were extracted from recommendations found through systematic searches of national and international guidelines, and formatted with explicit criteria for inclusion, exclusion, time frame and setting. Experts reviewed the indicators using a multi-round modified Delphi process and collaborative online wiki to develop consensus on what constituted appropriate care.

RESULTS

From 121 clinical practice guidelines, 1098 recommendations were used to draft 451 proposed appropriateness indicators. In total, 61 experts (n = 24 internal reviewers, n = 37 external reviewers) reviewed these indicators over 40 weeks. A final set of 234 indicators resulted, from which 597 indicator items were derived suitable for medical record audit. Most indicator items were geared towards capturing information about under-use in healthcare (n = 551, 92%) across emergency department (n = 457, 77%), hospital (n = 450, 75%) and general practice (n = 434, 73%) healthcare facilities, and based on consensus level recommendations (n = 451, 76%). The main reason for rejecting indicators was 'feasibility' (likely to be able to be used for determining compliance with 'appropriate care' from medical record audit).

CONCLUSION

A set of indicators was developed for the appropriateness of care for 21 paediatric conditions. We describe the processes (methods), provenance (origins and evolution of indicators) and products (indicator characteristics) of creating clinical indicators within the context of Australian healthcare settings. Developing consensus on clinical appropriateness indicators using a Delphi approach and collaborative online wiki has methodological utility. The final indicator set can be used by clinicians and organisations to measure and reflect on their own practice.

TIF 2.0: The Thal e-Course and TIF Expert Patients’ Programme for Disease-Related Education and Self-Management Skills in Thalassaemia

In response to the fundamental shift that has been taking place in the way chronic diseases are perceived and managed and the increasingly established role of patients as equal partners in the management of their condition, the Thalassaemia International Federation (TIF) has undertaken the design and development of a comprehensive online Expert Patients’ Programme (EPP) for patients with thalassaemia. Focusing particularly on β-thalassaemia, the most severe form of thalassaemia, the goal of the programme is to develop patients’ disease-related knowledge and self-care skills and enable them to co-manage their disease in a meaningful partnership with their treating physicians. An important goal of this ecourse is to empower patients to advocate for the improvement of national treatment services in every affected country. The aim of this article is threefold: (1) Relate TIF’s EPP with the goals and outcomes of other EPPs, as they are made available in the literature. (2) Describe the rationale and distinguishing features of TIF’s EPP on the basis of learning theories of knowledge acquisition and attrition, and best practices from the scientific disciplines of Human Computer Interaction (HCI) and Technology-Assisted Learning (TEL). (3) Relay the objectives of TIF’s EPP and the intended international impact in relation to TIF’s mission.

Quality of Web Information About Palliative Care on Websites from the United States and Japan: Comparative Evaluation Study

BACKGROUND

Patients and their families are able to obtain information about palliative care from websites easily nowadays. However, there are concerns on the accuracy of information on the Web and how up to date it is.

OBJECTIVE

The objective of this study was to elucidate problematic points of medical information about palliative care obtained from websites, and to compare the quality of the information between Japanese and US websites.

METHODS

We searched Google Japan and Google USA for websites relating to palliative care. We then evaluated the top 50 websites from each search using the DISCERN and LIDA instruments.

RESULTS

We found that Japanese websites were given a lower evaluation of reliability than US websites. In 3 LIDA instrument subcategories-engagability (P<.001), currency (P=.001), and content production procedure (P<.001)-US websites scored significantly higher and had large effect sizes.

CONCLUSIONS

Our results suggest that Japanese websites have problems with the frequency with which they are updated, their update procedures and policies, and the scrutiny process the evidence must undergo. Additionally, there was a weak association between search ranking and reliability, and simultaneously we found that reliability could not be assessed by search ranking alone.

STANDING Collaboration: a study protocol for developing clinical standards

INTRODUCTION

Despite widespread availability of clinical practice guidelines (CPGs), considerable gaps continue between the care that is recommended ('appropriate care') and the care provided. Problems with current CPGs are commonly cited as barriers to providing 'appropriate care'.Our study aims to develop and test an alternative method to keep CPGs accessible and up to date. This method aims to mitigate existing problems by using a single process to develop clinical standards (embodied in clinical indicators) collaboratively with researchers, healthcare professionals, patients and consumers. A transparent and inclusive online curated (purpose-designed, custom-built, wiki-type) system will use an ongoing and iterative documentation process to facilitate synthesis of up-to-date information and make available its provenance. All participants are required to declare conflicts of interest. This protocol describes three phases: engagement of relevant stakeholders; design of a process to develop clinical standards (embodied in indicators) for 'appropriate care' for common medical conditions; and evaluation of our processes, products and feasibility.

METHODS AND ANALYSIS

A modified e-Delphi process will be used to gain consensus on 'appropriate care' for a range of common medical conditions. Clinical standards and indicators will be developed through searches of national and international guidelines, and formulated with explicit criteria for inclusion, exclusion, time frame and setting. Healthcare professionals and consumers will review the indicators via the wiki-based modified e-Delphi process. Reviewers will declare conflicts of interest which will be recorded and managed according to an established protocol. The provenance of all indicators and suggestions included or excluded will be logged from indicator inception to finalisation. A mixed-methods formative evaluation of our research methodology will be undertaken.

ETHICS AND DISSEMINATION

Human Research Ethics Committee approval has been received from the University of South Australia. We will submit the results of the study to relevant journals and offer national and international presentations.

Clinical calculators in hospital medicine: Availability, classification, and needs

OBJECTIVE

Clinical calculators are widely used in modern clinical practice, but are not generally applied to electronic health record (EHR) systems. Important barriers to the application of these clinical calculators into existing EHR systems include the need for real-time calculation, human-calculator interaction, and data source requirements. The objective of this study was to identify, classify, and evaluate the use of available clinical calculators for clinicians in the hospital setting.

METHODS

Dedicated online resources with medical calculators and providers of aggregated medical information were queried for readily available clinical calculators. Calculators were mapped by clinical categories, mechanism of calculation, and the goal of calculation. Online statistics from selected Internet resources and clinician opinion were used to assess the use of clinical calculators.

RESULTS

One hundred seventy-six readily available calculators in 4 categories, 6 primary specialties, and 40 subspecialties were identified. The goals of calculation included prediction, severity, risk estimation, diagnostic, and decision-making aid. A combination of summation logic with cutoffs or rules was the most frequent mechanism of computation. Combined results, online resources, statistics, and clinician opinion identified 13 most utilized calculators.

CONCLUSION

Although not an exhaustive list, a total of 176 validated calculators were identified, classified, and evaluated for usefulness. Most of these calculators are used for adult patients in the critical care or internal medicine settings. Thirteen of 176 clinical calculators were determined to be useful in our institution. All of these calculators have an interface for manual input.

What Are We Looking for in Computer-Based Learning Interventions in Medical Education? A Systematic Review

Background

Computer-based learning (CBL) has been widely used in medical education, and reports regarding its usage and effectiveness have ranged broadly. Most work has been done on the effectiveness of CBL approaches versus traditional methods, and little has been done on the comparative effects of CBL versus CBL methodologies. These findings urged other authors to recommend such studies in hopes of improving knowledge about which CBL methods work best in which settings.

Objective

In this systematic review, we aimed to characterize recent studies of the development of software platforms and interventions in medical education, search for common points among studies, and assess whether recommendations for CBL research are being taken into consideration.

Methods

We conducted a systematic review of the literature published from 2003 through 2013. We included studies written in English, specifically in medical education, regarding either the development of instructional software or interventions using instructional software, during training or practice, that reported learner attitudes, satisfaction, knowledge, skills, or software usage. We conducted 2 latent class analyses to group articles according to platform features and intervention characteristics. In addition, we analyzed references and citations for abstracted articles.

Results

We analyzed 251 articles. The number of publications rose over time, and they encompassed most medical disciplines, learning settings, and training levels, totaling 25 different platforms specifically for medical education. We uncovered 4 latent classes for educational software, characteristically making use of multimedia (115/251, 45.8%), text (64/251, 25.5%), Web conferencing (54/251, 21.5%), and instructional design principles (18/251, 7.2%). We found 3 classes for intervention outcomes: knowledge and attitudes (175/212, 82.6%), knowledge, attitudes, and skills (11.8%), and online activity (12/212, 5.7%). About a quarter of the articles (58/227, 25.6%) did not hold references or citations in common with other articles. The number of common references and citations increased in articles reporting instructional design principles (P=.03), articles measuring online activities (P=.01), and articles citing a review by Cook and colleagues on CBL (P=.04). There was an association between number of citations and studies comparing CBL versus CBL, independent of publication date (P=.02).

Conclusions

Studies in this field vary highly, and a high number of software systems are being developed. It seems that past recommendations regarding CBL interventions are being taken into consideration. A move into a more student-centered model, a focus on implementing reusable software platforms for specific learning contexts, and the analysis of online activity to track and predict outcomes are relevant areas for future research in this field.

Written and Online Residency Guidebook to Improve Resident Efficiency and Knowledge of Best Patient Care Practices

Introduction

Residents at most institutions change rotations every 2 to 4 weeks. It often takes significant time for residents to become acclimated to the different protocols, expectations, and environments of each unique rotation. As a result, residents often spend time searching for answers, time that could be spent in outside learning and direct patient care. The goal of this resource is to provide a novel guidebook that improves residents' efficiency and knowledge of best patient care practices.

Methods

The guidebook begins with an introductory chapter with key contact information that can be filled in for the user's institution, which is followed by 16 rotation-specific chapters. A rotation-based approach was chosen as it focuses the content on the most pertinent information. Thus, trainees can quickly read a chapter to cover the most pertinent content for their current rotation. As a surrogate marker for efficiency, noon-conference attendance logs were queried to assess improvement in on-time attendance after introduction of the guidebook.

Results

After introduction of the learning resources, on-time arrival to noon conference improved for all residents and interns. Guidebook survey results were universally favorable; however, around half of respondents stated that they used the guidebook once or less per rotation.

Discussion

Underutilization of these resources potentially contributed to the lack of a statistically significant improvement overall. Future directions should focus on augmenting the quality and utilization of the guidebook and then reevaluating if, once well adopted, there is a sustained benefit.

The Sydney West Knowledge Portal: Evaluating the Growth of a Knowledge Portal to Support Translational Research

Background

The Sydney West Translational Cancer Research Centre is an organization funded to build capacity for translational research in cancer. Translational research is essential for ensuring the integration of best available evidence into practice and for improving patient outcomes. However, there is a low level of awareness regarding what it is and how to conduct it optimally. One solution to addressing this gap is the design and deployment of web-based knowledge portals to disseminate new knowledge and engage with and connect dispersed networks of researchers. A knowledge portal is an web-based platform for increasing knowledge dissemination and management in a specialized area.

Objective

To measure the design and growth of an web-based knowledge portal for increasing individual awareness of translational research and to build organizational capacity for the delivery of translational research projects in cancer.

Methods

An adaptive methodology was used to capture the design and growth of an web-based knowledge portal in cancer. This involved stakeholder consultations to inform initial design of the portal. Once the portal was live, site analytics were reviewed to evaluate member usage of the portal and to measure growth in membership.

Results

Knowledge portal membership grew consistently for the first 18 months after deployment, before leveling out. Analysis of site metrics revealed members were most likely to visit portal pages with community-generated content, particularly pages with a focus on translational research. This was closely followed by pages that disseminated educational material about translational research.

Conclusions

Preliminary data from this study suggest that knowledge portals may be beneficial tools for translating new evidence and fostering an environment of communication and collaboration.

Impact of Implementing a Wiki to Develop Structured Electronic Order Sets on Physicians' Intention to Use Wiki-Based Order Sets

BACKGROUND

Wikis have the potential to promote best practices in health systems by sharing order sets with a broad community of stakeholders. However, little is known about the impact of using a wiki on clinicians' intention to use wiki-based order sets.

OBJECTIVE

The aims of this study were: (1) to describe the use of a wiki to create structured order sets for a single emergency department; (2) to evaluate whether the use of this wiki changed emergency physicians' future intention to use wiki-based order sets; and (3) to understand the impact of using the wiki on the behavioral determinants for using wiki-based order sets.

METHODS

This was a pre/post-intervention mixed-methods study conducted in one hospital in Lévis, Quebec. The intervention was comprised of receiving access to and being motivated by the department head to use a wiki for 6 months to create electronic order sets designed to be used in a computer physician order entry system. Before and after our intervention, we asked participants to complete a previously validated questionnaire based on the Theory of Planned Behavior. Our primary outcome was the intention to use wiki-based order sets in clinical practice. We also assessed participants' attitude, perceived behavioral control, and subjective norm to use wiki-based order sets. Paired pre- and post-Likert scores were compared using Wilcoxon signed-rank tests. The post-questionnaire also included open-ended questions concerning participants' comments about the wiki, which were then classified into themes using an existing taxonomy.

RESULTS

Twenty-eight emergency physicians were enrolled in the study (response rate: 100%). Physicians' mean intention to use a wiki-based reminder was 5.42 (SD 1.04) before the intervention, and increased to 5.81 (SD 1.25) on a 7-point Likert scale (P =.03) after the intervention. Participants' attitude towards using a wiki-based order set also increased from 5.07 (SD 0.90) to 5.57 (SD 0.88) (P =.003). Perceived behavioral control and subjective norm did not change. Easier information sharing was the most frequently positive impact raised. In order of frequency, the three most important facilitators reported were: ease of use, support from colleagues, and promotion by the departmental head. Although participants did not mention any perceived negative impacts, they raised the following barriers in order of frequency: poor organization of information, slow computers, and difficult wiki access.

CONCLUSIONS

Emergency physicians' intention and attitude to use wiki-based order sets increased after having access to and being motivated to use a wiki for 6 months. Future studies need to explore if this increased intention will translate into sustained actual use and improve patient care. Certain barriers need to be addressed before implementing a wiki for use on a larger scale.