The cost of designing, developing, and marketing a new pharmaceutical drug can literally exceed a billion dollars. Even millions more are invested in non-industry trials to demonstrate the efficacy — or lack thereof — of these drugs with certain medical conditions or clinical parameters. The process of getting FDA approval is another separate adventure in itself. Given the enormous effort in ensuring that drugs are safe and efficacious, it is curious that the same stringency is not applied in prescribing these drugs at the time of health care delivery.

Disclaimer: this is not a critique of health care professionals, but a discussion of some challenges surrounding medication reconciliation.
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The iPhone App store is a veritable treasure chest of free and cheap applications, ranging from productivity tools and reference guides to arcade games to pass the time. As of this writing, there are over 800 applications categorized as “Medical”. For the busy physician and student, wandering through the labyrinth of apps can be a daunting and time-consuming task. The apps can furthermore vary widely in intended use, as do their quality and completeness.

On The Wards has taken the task to list the top medical apps for the iPhone. “Top” is a subjective word, so here are the criteria for inclusion in this list:

Not surprisingly, there were innumerable apps that qualified for inclusion, according to the above criteria. Many of them were excellent and very useful for work on rounds and in general inpatient care. I nevertheless had to limit the list to ten choices. Ultimately, those apps that ranked lower in popularity had to be excluded (I may reconsider them for inclusion in a future list).

Without further ado, here is the On The Wards compilation of the top 10 iPhone medical apps for the wards:

1. Medscape (WebMD) – This is iTune’s most popular medical app, providing a comprehensive drug reference (over 6,000 generic and brand-name drugs, hundreds of herbals and supplements), specialty-specific medical news, continuing medical education (CME), and health directory.

2. Epocrates Rx (Epocrates) – This venerable drug reference has served medical students, residents, and attending physicians since the early days of the original Palm OS. It has since been upgraded and ported to Windows Mobile, Blackberry, and now the iPhone. Epocrates Rx contains information on over 3,300 drugs, including their dosing, adverse effects, drug interactions, pricing, and pictures. This version also has several built-in medical calculations.

3. Medical Encyclopedia (University of Maryland Medical System) – This large medical reference available in both English and Spanish includes over 50,000 pages of in-depth information on symptoms, injury, disease, and surgery. Beef up your fund of knowledge or look up information while on rounds.

4. MedCalc (Mathias Tschopp & Pascal Pfiffner) – No smartphone used by physicians would be complete without a medical calculator. MedCalc offers a “very large selection of formulas and scores” in 4 languages (English, French, German, and Spanish). There is also support for SI and US units.

5. EyeChart (Dok LLC) – This portable Snellen Eye Chart is simple in design and use, but would be invaluable for a quick-and-dirty assessment of a patient’s visual acuity request an ophthalmology consult.

6. BLACKBAG (Ortho-McNeil-Janssen Pharmaceuticals) – The app is a medical news and video aggregator for nearly 40 specialties and categories. The function replicates the medical feeds found in the Medscape app, but the choices of news articles are slightly less technical without sacrificing clinical relevance. This may or may not be a feature, depending on the user. The user interface also looks more elegant, but lacks the ability to save or e-mail articles of interest.

7. ACC Pocket Guidelines (Skyscape) – This reference includes a portable version of the American College of Cardiology (ACC) and American Heart Association (AHA) Practice Guidelines, including standard practices for the management of cardiac patients, use of cardiac imaging modalities, perioperative cardiovascular evaluation for noncardiac surgery, and other related topics.

8. STAT Cardiac Clearance (Austin Physician Productivity) – The cardiovascular evaluation of patients undergoing noncardiac surgery is described in the ACC/AHA Practice Guidelines. This app compresses the information into a quick-access algorithm for perioperative assessment of a patient’s appropriateness for noncardiac surgery.

9. PEPID (PEPID) – This robust toxicology reference provides information on the management of diverse toxicology emergencies, such as drug/chemical ingestion, gas inhalation, occupational exposures, and food allergies. It also includes a comprehensive antidote reference, toxicology-specific lab profiles, and poisonous plant images. This app may be of higher yield in the emergency department than on the wards, but the inpatient teams will eventually be responsible for affected patients once they get admitted.

10. STAT Insulin DM2 (Austin Physician Productivity) – The app applies the 2006 consensus algorithm developed by the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD) for the initiation and adjustment of antiglycemic therapy in type 2 diabetes.

As mentioned earlier, there are many other outstanding apps not included in this list due to lack of space. With a vigorously active software development for the iPhone, coupled with medicine’s embrace of emerging technologies, this list will undoubtedly evolve over time. If you have any suggestions or beefs about any medical apps for the wards, feel free to leave me a note. We hope you find this list helpful for your education and work, and we look forward to seeing you with the next edition of the On The Wards top 10.

For a growing non-exhaustive list of iPhone medical apps, also check out our Squidoo lens.

With the national push toward electronic medical records, there have been active efforts to upgrade clinical data and systems software. At some institutions, an effect of this transition is the migration from the traditional voice dictation systems or paper clinic notes to a typed electronic record.

A recent study at the University of Toronto Faculty of Medicine sought to evaluate the overall quality of electronic discharge summaries (EDS) compared to their traditional dictated counterparts. The measure for quality was based on a 100-point visual analogue scale rating the satisfaction of primary care physicians (PCPs) who receive the discharge summaries. Other endpoints studied included the satisfaction of house officers using either system (again, using a 100-point visual analogue scale), adverse outcomes after discharge (combined emergency department visits, readmissions, and death), and patient understanding of the discharge details.

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Although the core business of the U.S News & World Report franchise is the delivery of mainstream news, it is best known for annual rankings of the best colleges, graduate schools, and hospitals. Like clockwork every July, the magazine just released today its rankings for the best hospitals in the United States.

The overall ranking is based on the sum of points assigned to a hospital’s top-tier specialty services. A hospital gets 2 points for each specialty ranked “at or close to the top” when compared to its peer hospitals. They receive 1 point for each specialty that is ranked lower.

Topping the list this year, and for the nineteenth consecutive time, is the Johns Hopkins Hospital in Baltimore, Maryland. The hospital has 3 specialties ranked as the top in the nation, including Urology, Rheumatology, and Otolaryngology (Ear, Nose, and Throat). It also has 10 other specialties within the top-three rank. Its closest rival, the Mayo Clinic in Rochester, Minnesota, also has 3 first-ranked specialties, including Endocrinology, Gastroenterology, and Neurology/Neurosurgery. The remaining few contenders on the list may have at most one or two top-ranked specialties. The Ronald Reagan UCLA Medical Center, which has now taken the third spot since 2007, and the title “Best in West [Coast]” for the 20th consecutive year, leads the nation in geriatric care. The top 7 institutions on the list has not changed since last year.

Drum roll for the top twenty-one (#10 and #11, #17 and #18 below are tied) …

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Welcome to the new year! Unlike last year when I had the day off, this time I was on call. Although I did not feel the transition from one year to the next (it was just another day), I managed to slip a “happy new year” greeting either at the beginning or end of my first conversations of the day. Some patients reacted with a pleasant response, but for most, it was another reminder that they were in the hospital during this festive time. Just as 2008 rapidly approached, a lot of patients were strongly negotiating to be discharged. I cannot blame them. I myself would much prefer to be at home, but the work must go on 24 hours a day, 365.5 days a year. MRSA (methicillin-resistant Staphylococcus aureus) does not keep a watch. And there is the deluge of trauma, intoxication, congestive heart failure, pancreatitis, reactive airway disease, etc. that roll in after a night of dietary (or drug) indiscretion. In any case, I love what I do and will gladly serve these needs. It was just another day, but it is now a new year. Happy new year!