PRACTICE INSIGHTS

iPhones, iPads, and Medical Applications for Antimicrobial Stewardship

Debra A. Goff, Pharm.D., FCCP One of the most important antimicrobial stewardship activities of the infectious diseases pharmacist and physician is to provide education and clinical information about antimicrobials to health care professionals and patients; however, clinician training and continuing education in appropriate antimicrobial use in the United States are highly variable and nonstandardized. The iPhone, iPad, and the availability of more than 12,000 medical applications (referred to as apps) allow stewardship programs the ability to integrate novel technology with point-of-care education. This article reviews medical apps for antimicrobial stewardship programs to use on the iPhone or iPad. Key Words: antimicrobial stewardship, iPad, iPhone, education, technology, medical applications. (Pharmacotherapy 2012;32(7):657661)

One of the most important stewardship activities of the infectious diseases pharmacist and physician is to provide education about antimicrobials to health care professionals.1, 2 This is considered an essential stewardship element; however, clinician training and continuing education in appropriate antimicrobial use in the United States are highly variable and nonstandardized.3 One of the barriers to improved pedagogy is that clinicians usually teach the way they were taught. For example, traditional methods of educating students, house staff, fellows, and colleagues about antimicrobial stewardship include didactic lectures, grand rounds, case conferences, bedside teaching on rounds, pocket books, the hospital intranet, and individual one-on-one discussions. In 2008, medical applications (referred to as apps) became available for use on an iPhone as a new way to access medical information at the point of patient care. The first article to discuss how to use infectious diseases apps on an iPhone was published in 2010.4 The shift toward mobile medical apps and the Internet as a preferred way to access medical information was identified in a survey of internal medicine house staff.5 The challenge remains how best to deliver relevant information where it is most needed. For the infectious diseases steward, this

means having the most up-to-date information at hand to make timely, effective treatment decisions at the point of care. A recent study found that hospitals that use UpToDate, a desktop clinical knowledge system also available as an app, had shorter length of stay, lower risk-adjusted 30-day mortality rates, and better quality performance than hospitals without this system.6 This suggests that using computerized tools as a method to educate others or oneself at the point of care could be helpful in improving care. According to a May 2011 study, 75% of U.S. physicians own some form of Apple mobile devices.7 These devices allow access to the Apple App Store where more than 15 billion apps have been downloaded.8 As there are more than 12,000 medical apps, it becomes time consuming to find relevant apps. Apple responded to this by creating a special section called the Apps for Healthcare Professionals category in iTunes. Six medical categories are defined: reference, education, electronic medical records and patient monitoring, imaging, point of care, and personal care. Unfortunately, several apps are not categorized correctly. In addition, the apps that are included are targeted only to physicians; other health care providers, including pharmacists and nurses, are excluded.

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PHARMACOTHERAPY Volume 32, Number 7, 2012 management, images, drug therapy, follow-up, background, and references. The news feature allows the user to tag infectious diseases so that daily updates on key new articles from numerous journals may be viewed. Reference information is updated every 90 days or sooner if needed. An Internet connection is not required once the information has been downloaded. The authors include physicians and pharmacists. Epocrates Rx This is one of the most downloaded app reference resources used by health care providers at the point of care. It provides clinical information, updated weekly, written by physicians and pharmacists on prescription drugs and overthe-counter (OTC) drug products. The drug interaction checker can assess up to 30 drugs at a time. Dosing calculators are available in addition to up-to-date infectious diseases medical news written by John Bartlett M.D., Professor of Medicine, Division of Infectious Diseases at the Johns Hopkins University. He provides commentaries on articles from numerous journals every 2 weeks and provides each article with a rating of one to three stars based on the significance of the article. Key abstracts from infectious diseases conferences, clinical news, and conference highlights are also reviewed. An Internet connection is required. Micromedex Drug Information This is a useful resource to access basic information on more than 4500 drugs. Without an Internet connection, one can browse by drug name or class to find the basics for any antimicrobial. Both U.S. Food and Drug Administration (FDA)-labeled and nonFDA labeled indications are listed, and dosing, dosage adjustments, mechanisms of action, pharmacokinetics, drug monitoring, how the drug is supplied, and clinical teaching points are provided. This is a fast way to search for specific drug information that is differentiated as FDA-labeled and nonFDA labeled indications. The ongoing evidence-based reviews are written by physicians, pharmacists, and nurses, and are updated as needed. Lexi-Drugs This is a comprehensive drug database with monographs that cover adverse reactions, contraindications, dosing, drug safety issues,

Identification of Reviewed Applications The Apple App store was accessed and the search term medical was used to identify 12,840 iPhone and 4569 iPad apps. The search was narrowed to infectious diseases, and 44 apps for the iPhone or iPad were found. Reviews from iMedicalApps, an independent online medical publication written by physicians and medical students who provide commentary and reviews of apps based on their own experiences in the hospital, were used to identify medical apps that did not appear in the Apple App store search due to improper categorization. iMedicalApps has been listed by Cochrane Reviews as an evidence-based trusted Web site.9 Apps that were written in languages other than English, targeted to noninfectious diseases practitioners, or received poor customer ratings were excluded. The final selection represents 17 apps that are relevant to antimicrobial stewardship programs and can enhance clinical care by aiding in rapid access to information at the point of care. Table 1 provides a summary of the selected apps grouped into the following categories: drug Information, education calculators, reference, epidemiology, and news. Drug Information Medscape This ranked as the number one downloaded free medical app in 2010. It offers more than 8000 drug references, 4000 disease and clinical references, 2500 clinical images and procedure videos, a drug interaction tool checker for the entry of up to 30 drugs, free continuing medical education for physicians, and free Accreditation Council for Pharmacy Education credit for pharmacists. Search features allow sorting by drugs, conditions, or procedures. In the diseases and conditions section authored by infectious diseases physicians, an overview of the infectious disease is provided followed by the clinical presentation, differential diagnoses, workup, treatment and

From the Department of Pharmacy, The Ohio State University Medical Center, Columbus, Ohio. For reprints, visit https://caesar.sheridan.com/reprints/ redir.php?pub=10089&acro=PHAR. For questions or comments, contact Debra A. Goff, Pharm.D., FCCP, Department of Pharmacy, The Ohio State University Medical Center, 410 West 10th Avenue, Room 368 Doan Hall, Columbus, OH 43210; e-mail: Debbie.goff@osumc.edu.

iPADS, iPHONES, APPS, AND ANTIMICROBIAL STEWARDSHIP Goff

Category and Name Drug Information Medscape Epocrates Rx Micromedex Drug Information Lexi-Drugs Education idPodcast Sanford Guide to Antimicrobial Therapy Johns Hopkins ABX guide UpToDate online Cost Free Free Free $75/yr Free $29.99/yr $39.95/yr $495/yr General Description

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Table 1. Description of Medical Applications (Apps) from the Apple App Store for Antimicrobial Stewardship Programs

A drug and disease reference, images, drug interaction tool checker, free CME and ACPE credit Drug information, drug interactions, pill identification, and medical calculators; infectious diseases articles reviewed and rated every 2 wks by John Bartlett, M.D. Detailed drug information including off-label indications on more than 4500 drugs Comprehensive drug database including international brand names Infectious diseases podcasts by infectious diseases physicians and pharmacists from the University of South Florida Critical information on treatment of infectious diseases, for timely, effective decisions at the point of care Evidenced-based information on the treatment of infectious diseases to help clinicians make decisions at the point of care Comprehensive evidence-based referenced resource of literature for adults and pediatrics; offers detailed answers to clinical questions; the app is free with a paid online subscription; the mobile complete app allows access while offline for an additional $49/yr Three-dimensional rotating human body used to view the human anatomy

Blausen Human Atlas Lite Calculators MedCalc Qx Calculate Reference NEJM This Week PubMed on Tap Lite Epidemiology iScrubLite HealthMap: Outbreaks Near Me News MedPage

Free

$0.99 Free

Medical calculator with an extensive list of 200 formulas One hundred fifty unique calculators and decision support tools with interactive questions Articles from the New England Journal of Medicine, updated every Wednesday Searches of PubMed to find reference information; results can be e-mailed Record hand-hygiene observations and transmittal of results by e-mail to hospital epidemiologist Real-time disease outbreak information with an interactive map

Free Free Free Free

Free

The University of Pennsylvania School of Medicine Office of Continuing Medical Education sponsors the breaking medical news alerts and provides a summary with actionable information

CME = Continuing Medical Education; ACPE = Accreditation Council for Pharmacy Education.

pharmacodynamics and pharmacokinetics, special alerts (including new FDA warnings), and international brand names from more than 100 countries. Updates written by a multidisciplinary in-house clinical staff are posted multiple times/ week. An Internet connection is required. Education idPodcasts This is a learning app of infectious diseases topics viewed as podcasts. More than 100 hours of infectious diseases podcasts are streamed to an iPhone or iPad through a WiFi connection, or the

content can be downloaded to iTunes and viewed on the go without an Internet connection. A new feature includes international podcasts in Spanish and Mandarin Chinese. The podcasts are categorized by title, author, and subject. Infectious diseases physicians and Pharm.D.s present lectures with slides for viewing on an iPad. The content is updated weekly. Physicians from the University of South Florida Division of Infectious Diseases designed it and are the authors. The Sanford Guide to Antimicrobial Therapy This app features infectious diseases and clinical conditions, antiinfective drug information,

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PHARMACOTHERAPY Volume 32, Number 7, 2012 backgrounds. This app does not require updates because it is a visual app. Calculators MedCalc A medical calculator developed by two physicians with an extensive list of 200 formulas including Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II (SAPS II) severity scores; Systemic Inflammatory Response Syndrome (SIRS) criteria; Confusion, Urea Nitrogen, Respiratory Rate, Blood Pressure, 65 Years of Age and Older (CURB-65) severity score for communityacquired pneumonia; sample size and need-totreat calculations; and likelihood ratios. A reference is provided for each formula, and the app is updated several times a year. Internet connectivity is not required. Therapeutic drug monitoring formulas are not included. Qx Calculate This app, developed by physicians, provides 150 unique calculators and decision-support tools. Interactive questions allow this app to calculate the CURB-65 score for pneumonia. In addition, it provides the estimated 30-day mortality and suggested triage to intensive care unit (ICU) or non-ICU beds. Internet connectivity is not required. It is updated every 8 weeks. Therapeutic drug monitoring formulas are not included. References NEJM This Week This app provides access to recent articles in The New England Journal of Medicine (NEJM) published online, images, weekly audio summaries, and procedure videos. Articles are updated every Wednesday. Internet connectivity is required. PubMed on Tap Lite The app searches PubMed to find reference information. The results may be e-mailed as formatted text or as a research information system tagged record, ready to be imported into reference management applications such as EndNote. An Internet connection is required.

comparative spectra of activity, therapeutic adjuncts, and expanded coverage of topics compared with the print edition. Conditions are organized by four types: bacterial, fungal, mycobacterial, and viral. It provides recommendations for surgical prophylaxis as well as drug information covering pharmacology, adverse effects, drug-drug interactions, and dosage adjustments, all supported by editorial commentary and references. Internet connectivity is only required for the download and updates. It is updated on an ongoing basis based on new published literature, user feedback, and continuing editorial review. The authors are infectious diseases physicians and a Pharm.D. Johns Hopkins ABX Guide This comprehensive app organizes the details of diagnosis, drug indications, dosing, pharmacokinetics, adverse effects, drug interactions, pathogens, disease management, and vaccines into quick-read entries. Medical literature with reference links is provided. Internet connectivity is required only for the download and future updates that occur on a monthly basis. The authors are infectious diseases physicians and Pharm.D.s from Johns Hopkins University School of Medicine. UpToDate This is an evidence-based, comprehensive, referenced app subject to a peer-review process. Topics are written by physicians with colleagues serving as co-authors, editors, and peer reviewers. The drug information database contains topics that include information about usual dosages and adverse reactions. An Internet connection is required. Information is updated continuously. There are three types of subscriptions: individual clinician subscription, individual trainee subscription, and site subscriptions. Blausen Human Atlas HD Lite This app is a powerful visual point-of-care patient education tool. The human body is shown in three dimensions (3D) and can be rotated 360 degrees. The quality of the 3D color images is outstanding on the iPad and can be viewed without an Internet connection. Videos require an Internet connection. The authors include physicians and animators with medical

iPADS, iPHONES, APPS, AND ANTIMICROBIAL STEWARDSHIP Goff Epidemiology iScrub Lite This is an app from the epidemiology group at the University of Iowa for health care professionals who want to use a mobile device to record hand hygiene compliance. Observations may be documented without an Internet connection, but when data are transferred to infection control by e-mail, an Internet connection is necessary. HealthMap: Outbreaks Near Me This app provides real-time disease outbreak information. It integrates outbreak data of varying reliability, ranging from news sources (e.g., Google News) to personal accounts (e.g., ProMED) to validated official alerts (e.g., World Health Organization and Centers for Disease Control and Prevention). Developed by researchers from Childrens Hospital in Boston, the interactive map lets one set up an alert with a notice automatically sent whenever an outbreak is occurring in your area. This site relies on publicly available third-party information and, therefore, assumes no responsibility for its accuracy or completeness. An Internet connection is required. News MedPage The University of Pennsylvania School of Medicine Office of Continuing Medical Education and MedPage Today sponsor this breaking medical news coverage. Each article provides a summary with actionable information enabling the clinician to better understand the implications. News items are reviewed daily, the content is approved by a team of physicians, and the reviewers name is listed. Items can be limited to only infectious diseases news, saved and shared by e-mail. Drug monographs from Micromedex can be viewed offline. An Internet connection is required for breaking news, and the user must register with MedPage Today. Acknowledgments Conclusion

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Mobile technology on Apples iPad or iPhone allows health care providers access to clinical information at the point of care. Infectious diseases pharmacists and physicians can incorporate the use of medical apps in an antimicrobial stewardship program to help enhance the infectious diseases knowledge of health care providers at the point of care and to assist in ensuring that the steward has the most current information.

The author would like to thank Marva Tschampel, R.Ph., and Rupal Parbhoo, Pharm.D., for reviewing this manuscript, and Jessica West, M.P.H., for help with editing.

References
1. Dellit TH, Owens RC, McGowen JE, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:15977. 2. Anonymous. ASHP statement on the pharmacists role in antimicrobial stewardship and infection prevention and control. Am J Health Syst Pharm 2010;67:5757. 3. Spellberg B, Blaser M, Guidos RJ, et al, for the Infectious Diseases Society of America. Combating antimicrobial resistance: policy recommendations to save lives. Clin Infect Dis 2011;52(Suppl 5):S397428. 4. Oehler RL, Smith K, Toney JF. Infectious diseases resources for the iPhone. Clin Infect Dis 2010;50(9):126874. 5. Oehler RL. A textbook case: making the transition to the online universe 2011 [Internet]. Tampa, FL: The American Journal of Medicine Blog; 2011. Available from http://amjmed.blogspot. com/2011/03/textbook-case-making-transition-to.html. Cited June 20, 2011. 6. Isaac T, Zheng J, Jha A. Use of UpToDate and outcomes in US hospitals. J Hosp Med 2012;7(2):8590. 7. Malloy M. 75 Percent Of U.S. physicians own some form of apple device according to new manhattan research study. [Internet]. New York, NY: Manhattan Research; 2011. Available from http://manhattanresearch.com/News-and-Events/PressReleases/physician-iphone-ipad-adoption. Cited June 20, 2011. 8. Muller T, Pope S. Apple app store downloads top 15 billion [Internet]. Cupertino: Apple; 2011. Available from http://www. apple.com/pr/library/2011/07/07ipad.html. Cited November 28, 2011. 9. Husain I, Wodajo F, Misra S, eds. iMedicalApps: Mobile Medical App Reviews & Commentary by medical professionals [Internet]. Available from http://www.imedicalapps.com. Cited June 20, 2011.