# What — no UptoDate? The Regina Qu'Appelle Health Region Library replaces UptoDate with BMJ's PointofCare

Barb Taylor

What — canceling UpToDate! I feel like I've just told Virginia there is no Santa Claus. The look on the young physician's face is one of shocked silence, disbelief, and utter disappointment. But hold on Virginia, we're not canceling Christmas, just replacing one present with what we hope is a fair alternative. This isn't going to be easy.

I bring up BMJ's PointofCare on Virginia's computer screen. She spends an hour navigating its “nice layout” then heads over to compare results on the computer we have running UpToDate. She leaves with an open mind. She likes BMJ's layout and the material seems comparable.

The Regina Qu'Appelle Health Region (RQHR) Library will be replacing Wolters Kluwer's UpToDate with BMJ's PointofCare in the hopes of providing a product of similar standard, but at a price that will ensure access to all health care workers in the region. Library Director Susan Baer points out that while UpToDate is a popular resource, the financial strain of providing site-wide access to this product necessitated exploring other resources. The RQHR Library currently provides UpToDate on three computers, two in the Regina General Hospital and one computer in the Pasqua hospital, not exactly a “point of care” resource for our users. Region-wide access is also unaffordable, so our rural physicians are out of luck. For the cost of having site-wide access to UpToDate, we can provide site-wide access to both BMJ's PointofCare and DynaMed.

It's no secret among librarians that UpToDate is a hit with physicians while packing a wallop on library budgets. An online search of medical library blogs shows the RQHR Library isn't the only health library forced to make tough decisions. The Krafty Librarian's 3 November 2006 blog entry titled “UpToDate Uproar” gives us insight into the tensions between librarians and UpToDate. The blog entry purports that librarians are forced to choose less expensive alternatives because cost just can't justify continuing to provide this service [1].

Why is UpToDate so popular? Jeff Mason, Client Services Librarian with the RQHR, believes UpToDate's appeal lies in its ease of use, interface, and layout of materials. Jeff took that appeal into consideration when he looked at other point-of-care products and chose BMJ's PointofCare as an alternative resource.

Recent studies have shown that UpToDate has some tough competitors challenging its favoured spot as a point-of-care (POC) tool for physicians, medical students, and librarians. The Health Sciences Library System, serving the University of Pittsburgh and the University of Pittsburgh Medical Center, reported its comparisons of five POC products (UpToDate, Clinical Evidence (BMJ), ACP PIER, DynaMed, and FIRSTConsult) at the 2009 Medical Library Association Conference. They compared the results for four conditions: hypertension, hyperlipidemia, carbon monoxide poisoning, and asthma, then determined the level of evidence of each reference. FIRSTConsult yielded higher levels of evidence supporting its monographs followed by Clinical Evidence, ACP PIER, DynaMed, and UpToDate. When ranked according to the last update of the monograph studied, DynaMed was head of the class. The authors caution that the results were based on a limited search and that results could vary depending on the topic [2].

In her 2008 article “An evaluation of the five most used evidence based bedside information tools in Canadian health libraries”, Alison Farrell concluded that while both UpToDate and BMJ Clinical Evidence were user friendly and informative, ACP Pier was deemed to be most inclusive of “levels of evidence”. Given 20 randomly chosen questions, UpToDate answered the highest number of questions at 14 but included levels of evidence for only one question. ACP Pier answered 10 questions and provided levels of evidence for all 10 [3].

In a study by seven health and medical librarians with the Texas Health Science Libraries Consortium, 13 products self-identified as POC tools were ranked in 18 categories, including levels of evidence, ease of navigation, and linkage to PubMed. ACP Pier and Clinical Evidence rated as the top two POC tools, with UpToDate falling in the middle categories [4]. So it seems that while UpToDate ranks as a good resource, it's not necessarily the best.

Is BMJ's PointofCare the answer? It's too soon to tell, but we've been happy with the results we're getting when searching diseases and conditions using this resource. PointofCare has an attractive, easy-to-navigate, one-page layout with seven tabs for specific searches of drugs, dis-eases, drug combinations, pill identification, medical calcu-
lations, tables, and links to clinical resources. Both PointofCare and UpToDate are updated as new information becomes available. Both employ American and Canadian physicians to cover topics. Both link to articles and abstracts in PubMed and journals to which the library subscribes. In the short time we've been using PointofCare, we've had positive feedback about subject coverage and usability.

One minor criticism would be that the “diseases” tab might be more appropriately termed “conditions” as it is inclusive of the latter.

I decided to see what response I got from UpToDate as to our decision to go with PointofCare for budgetary reasons. A representative from UpToDate returned my e-mail within the hour and has been in consultation with the library's director about the pricing of their product. UptoDate has expressed concern that our library will no longer be subscribing to their product. Maybe free enterprise and some quality competition will convince Wolters Kluwer to make UpToDate an affordable site-wide POC tool for medical/health libraries.

What is needed is more research about POC tools. Ideally that research will be undertaken on subjects who haven't had the opportunity to develop a bias towards any POC tools. In the meantime librarians will have to strike a balance be-

tween physician preference, quality of product, and what their budgets will allow.

## References

1. UpToDate Uproar. 2006 Nov 3 [cited 2009 Aug 28]. In: The Krafty Librarian Blog [Internet]. Available from: http://kraftylibrarian.com/2006_11_01_archive.html.

2. Ketchum A, Saleh A. The evidence behind Point of Care products. *HSLS Update* [Internet]. Pittsburgh: Health Sciences Library System Serving the University of Pittsburgh and UPMC; 2009 Jun [cited 2009 Aug 28]. Available from: http://www.hsls.pitt.edu/updatereport/?p=2050.

3. Farrell A. An evaluation of the five most used evidence based bedside information tools in Canadian health libraries. *Evid Based Libr Inf Pract*. 2008;3(2):3–17.

4. Trumble J, Anderson M, Caldwell M, et al. A systematic evaluation of evidence based medicine tools for Point-of-Care. Texas Health Science Libraries Consortium [Internet]. In: Proceedings of the 34th SCC/MLA Annual Meeting; 2006 Oct 20–24; College Station, (TX); [updated 2006 Nov; cited 2009 Aug 28]. Available from: http://ils.mdacc.tmc.edu/papers.html.