The Johns Hopkins Gazette: April 2, 2001
April 2, 2001
VOL. 30, NO. 28


Experts Launch 'Antibiotic Guide' for Handheld PC

Service available on Web and for PocketPC-based handheld computers

By Kate O'Rourke

Johns Hopkins Gazette Online Edition

Johns Hopkins today launched a rigorously peer-reviewed database and a point of care decision-support system designed to give office- and hospital-based physicians free and up-to-the-minute information on antibiotics and their proper use.

Capitalizing on the popularity of handheld pocket computers, and developed in part to address a growing national concern over antibiotic drug resistance and the inappropriate prescription of drugs, the Antibiotic Guide, also known as ABX Guide, is the first in a planned series of easily navigated, regularly updated digital medical specialty handbooks from Hopkins experts. The guide works on both the Web ( and PDAs, such as the Microsoft PocketPC.

Instead of carrying quickly outdated and limited paper versions of drug references, users of the ABX Guide carry critically edited electronic versions that boil down essential information on drug options and diagnostic criteria. Experts picked by Hopkins continually make updates to reflect changes in the field. The experts' comments are attributed, along with supporting citations in the literature. Emergency alerts, such as FDA recalls, can be "pushed" in an instant to all physician users who access the updated database regularly, preferably daily.

The guide offers information on more than 160 drugs and more than 140 diseases treated by both specialists and primary care physicians.

"We believe this guide and the technology on which it is based will rapidly advance evidence-based and outcomes-based medical care, and enrich medical education, while addressing key concerns such as medication errors, delays in the incorporation of new developments into practice, and antibiotic resistance, says John G. Bartlett, chief of the university's Division of Infectious Diseases, who championed the project for Hopkins. These and other concerns were raised in a recent, much publicized national report on the problems of antibiotic use in the United States issued by the Institute of Medicine.

The ABX Guide gives doctors who practice in even remote areas access to the same current diagnostic and treatment guidelines being followed at major medical institutions. The system also will help doctors cope with the estimated 1,500 treatment guidelines that government agencies and medical organizations have developed over the years in an effort to standardize best practices, according to Bartlett.

Unlike other existing digital guides involving infectious diseases, the ABX Guide is heavily annotated and carefully reviewed by specialists at Hopkins and other institutions. "Our strength is that we are teachers and researchers as well as clinicians and are ever aware of the need for information to be absolutely accurate and based on the best scientific evidence, not anecdote or convenience," says Walter Atha, director of the ABX Guide project and an emergency medicine physician at Hopkins. "These academic experts provide candid opinions about inappropriate medication use."

According to Atha, extending this application onto secure handheld devices, such as PocketPC, allows the physician to get large amounts of data in his or her hand. "The inclusion of the browser in the PocketPC provides the same look and feel as the browser on the desktop computer, which adds familiarity to the user."

Infectious disease experts who write the ABX Guide can update their assigned sections anytime, from anywhere they have access to the Internet, notes Sharon McAvinue, director of the parent Hopkins initiative known as POC-IT for Point of Care, Information Technology. McAvinue conceived of and spearheaded the ABX Guide project (see sidebar).

The Johns Hopkins University holds the copyright to all POC-IT content, including the ABX Guide. Under contract to Hopkins' Infectious Diseases division, Applied Theory, a New York-based company (NASDAQ: ATHY), constructed and will maintain the database and PDA applications. The ABX Guide and future POC-IT applications will be available soon for other PDA operating systems and on other devices such as smart phones.

"Almost all doctors prescribe antibiotics at one time or another," Atha says. "The ABX Guide isn't just for infectious disease specialists. It will serve the needs of doctors across all specialties. The ABX Guide is not designed to take the place of the physician's own experience or judgment," he adds. "The goal is to help physicians plan treatments by making the most current information available right at the point of care in the doctor's office or hospital."

Atha also notes, "One of the biggest challenges doctors face is trying to keep up with the thought leaders on antibiotic use. New research may find that some drugs aren't effective anymore against certain bacteria, for example, or that certain combinations of drugs shouldn't be used. That's why antibiotic guides are one of the most important types of reference a doctor uses."

There's too much new information being published in weekly and monthly journals for doctors to keep up with by referring to a guide that's updated only once a year, Atha says. "Our experts review all current relevant literature on the diagnosis and treatment of infectious diseases and compress that information into recommendations in the form of bullet points."

An important design feature of the ABX Guide, and other planned POC-IT applications, is the ability to gather information anonymously from users, who are required to complete a brief questionnaire on the ABX GuideWeb site in order to gain access to the database. POC-IT will then regularly prompt users to update their digest of medical information by downloading newer versions directly into their PDA through a cradle attached to their desktop computer.

Currently, as a physician downloads new information from the Web site, POC-IT will collect data about the viewing patterns of registered users. This information will be collected and uploaded from the PDA each time the doctor links to the site through the cradle. Researchers at Hopkins will match those data with answers to the user questionnaire, which consists of five brief demographic questions. The goal is to identify trends in medical practices. Findings will serve as the basis for academic publications and research opportunities.

"This will let us compile an extremely valuable database of prescribing behavior and antibiotic usage trends that reflects how specific diseases are being treated in different settings throughout the country, and could alert practitioners to potential public health problems," McAvinue says. "And because the information is collected anonymously, the names of individual physicians cannot be linked back to them unless they voluntarily submit their e-mail addresses. We believe that there is a wealth of unrecognized clinical expertise in the community that will formally contribute to the advancement of medical knowledge."

A Hopkins oversight board is being formed to consider the potential uses of aggregate data, both academically and commercially, according to McAvinue.

Development of the ABX Guide was funded through unrestricted educational grants to Hopkins POC-IT from Abbott Laboratories, Bristol-Myers Squibb Co., Merck & Co., Ortho McNeill Pharmaceutical, Pfizer Inc., Pharmacia and Roche Pharmaceuticals. Sponsors are acknowledged in a special section on the Web site, but no banner or commercial advertising exists in any of the applications.

The next Hopkins POC-IT guide, currently in development, will cover treatment of HIV/AIDS.

The ABCs of the 'ABX Guide'

The origin of Hopkins' Antibiotic Guide, or ABX Guide, and a planned family of guides, came not from a computer guru but from Sharon McAvinue, a nurse by training and a keen observer of how physicians really use information.

McAvinue came to Hopkins in 1988, first as a research nurse, then as a clinical practitioner in the Adult HIV Outpatient Service during the height of the AIDS epidemic in the United States.

In the mid-1990s, she began to seek ways to use the Internet to disseminate the most recent expert advice on HIV/AIDS therapy and began developing the widely regarded Hopkins HIV Web site

This educational forum now receives more than 150,000 monthly visitors looking for the latest information on the diagnosis, treatment and epidemiology of HIV/AIDS. Using the experience and skills developed during this project, she began to assist faculty from other divisions and departments within the School of Medicine to find funding for and develop their own Web sites.

Through these projects, McAvinue discovered that patients and doctors had a hunger for accurate and timely interactive sites. For example, patients and nonspecialist doctors particularly liked the interactive forum on the HIV Web site through which Joel Gallant, director of the Moore HIV clinic at Hopkins, answered questions submitted by Web site users. "Delivering expert assistance directly was what folks wanted most," McAvinue says.

She also found that doctors had little time to use the Internet or to sift through large volumes of information. "I found that doctors were far more likely to use devices like personal digital assistants and cell phones that delivered information faster while tapping into the Internet's power far more efficiently," McAvinue says.

In early 1998, this insight sparked the idea for the development of handheld guides and, after discussion with John Bartlett, director of the Division of Infectious Diseases, about a much-publicized national report on the problems of antibiotic misuse, the idea for the ABX Guide was born. McAvinue then recruited Walter Atha, an emergency medicine doctor with a passion and flare for information technology. Before enrolling in medical school, Atha directed the development and maintenance of several large databases for the Health Resources and Services Administration and for National AIDS Network, a nonprofit organization in Washington, D.C. And while caring for patients in the setting of frontline emergency medicine, he recognized the potential use of electronic media to deliver critical medical information in a useful manner.

"One of the biggest challenges doctors face is trying to keep up with the latest research on antibiotics," Atha says. "New research may find that some drugs aren't effective anymore against certain bacteria, for example, or that certain combinations of antibiotics shouldn't be used. A guide that includes the latest information is invaluable."

Under Bartlett's guidance, Atha and McAvinue gathered a team of Hopkins-picked experts to create the guide and continually make updates to reflect changes in the field.

While the Antibiotic Guide is the current darling baby of the Hopkins team, it won't be an only child for long. The Hopkins PDA initiative, called Point of Care Information Technology, or POC-IT, and directed by McAvinue, will expand over the next several months to include other specialties, including HIV/AIDS, arthritis and asthma, all of which will be updated regularly. "We plan to develop other medical applications that will integrate information technologies further into clinical practice, improving patient care," McAvinue says. "This is just the beginning."