An interesting article in Forbes (NHS readers be aware – IE6 hates Forbes) describing UpToDate as “Medicine’s Killer App”. It identifies some of the reasons that clinicians are so fond of what is essentially a textbook and adds an interesting perspective on some of the previous discussion around this product.
The UpToDate article is one of a series of four with the most interesting article for me being about Standards and practice. This is well worth a read for considering how guidance may and may not be adopted and when considering the Quality standards under development at NICE.
So Wolters Kluwer are buying UptoDate for probably something around $400 odd million? Well, UptoDate does apparently make around $80 million a year, and has seen “double-digit organic revenue growth” over the last 4 years, according to WK Health – but it does seem rather a lot of money, and apparently there was a bit of bidding war. WK do claim to be interested in dominating the point-of-care market so it looks like a strategically valid purchase, credit crunch or no credit crunch. But what can WK Health bring to the party? Apparently, “The combination of UpToDate and Wolters Kluwer Health provides the market with a unique value proposition for advancing patient care while reducing medical costs,” said Dr. Denise Basow, Editor-In-Chief of UpToDate. “Jointly, we can deliver a full suite of solutions to physicians and patients” [link]. I can’t really see how a clinical, point-of-care tool, particularly a non-EB tool, can have an impact on reducing medical costs; the needs of commissioning and procurement is totally different from the needs of a clinician on the ward. Still, what gets me is that, however popular it is to its users, UptoDate is pretty rubbish, don’t you think? Nobody likes it, apart from those pesky doctors… and they only like it because they or their mate probably wrote it. It’s old school. It’s opinion-based medicine. Yet it remains staggeringly successful. *he says with a heavy sigh.*
Where does evidence belong? An “Evaluation of the Five Most Used Evidence Based Bedside Information Tools in Canadian Health Libraries” suggests that of them (UpToDate, BMJ Clinical Evidence, First Consult, Bandolier and ACP Pier), clinicians preferred UpToDate and Clin Evid even though “neither product generally includes levels of evidence.” The author suggests that if a clinician wished to use these tools then it would be prudent to critically appraise the information they get before using them to guide patient care.
However, these are bedside tools we’re talking about here – there is not time, and indeed is this the place, to start appraising information. Clinicians consistently seem to like UpToDate because it speaks their language and gives relatively detailed guidance on what to do – it’s not really evidence-based, but that does not seem to do it any harm. It does not leave a clinician hanging with a Cochranesque “more research is required”. This is not to criticise Cochrane as it is a fundamentally different beast; surely no-one seriously thinks that Cochrane is suitable for bedside use, or that UpToDate is seriously an evidence-based resource (do they…)?
Arguably, trying to leverage in evidence “at the bedside” is the wrong place to do it; evidence needs to be introduced higher up the chain, where commissioning takes place, where patient-journey pathways are drawn up, where guidance is written and acted upon. We need to be ambitious and get evidence in up at the top. To try and ‘tack on’ a bit of evidence at the bedside is surely too little too late…(?)