Category: Medical Negligence

Utilizing the Power of the Web: Medical Resources for Attorneys

As a medical-legal consultant and Internet researcher I am asked every day to find authoritative medical literature references for a broad spectrum of topics. The information I am looking for may be used to support a claim, to debunk an expert theory, or to educate the attorney during the course of a case evaluation.

Changes in the way medical information is stored, accessed, and retrieved have created a wealth of health care information. The Internet provides free access to a great deal of the medical literature, either in full text or citation/abstract format.

Because anyone with access to the Web can establish a Web page, many medical sites contain little useful information, even though they may be visually appealing. For this reason, the quality of information available varies from very good to poor, and some sites even intend to mislead. It is important to search for peer reviewed information, from an authoritative source.

I. Define The Search

Before you start your search, be clear as to the specific type of information you are seeking. It may be a standard of care for a particular procedure, it may be the rate of occurrence for complications related to a specialized treatment, or it may be basic information defining a disease or particular injury. You must identify the main concepts in your topic and determine any synonyms, alternate spellings, or variant word forms for the concepts.

In order to define your search, you will need a grasp of basic medical terminology. The medical terms used in your search usually come from records showing a diagnosis or particular treatment. The terms may include the name of a medication or specialized medical equipment. It is a good idea to keep a medical dictionary and drug guidebook close at hand as references, because spelling of medical terms must be accurate in order to get relevant search results.

Because the Web is not indexed in any standard manner, finding information can seem difficult. Search engines are popular tools for locating web pages, but they often return thousands of results. Search engines crawl the Web and log the words from the web pages they find in their databases. Without a clear search strategy, using a search engine is like wandering aimlessly in the stacks of a library trying to find a particular book.

II. Performing the Search

Most of the major medical literature search sites have tutorials or help functions to assist you in customizing your search. It may take some time to learn how to master the specific commands and options offered by the various search engines, but it pays off by helping you avoid hundreds of hours fruitlessly searching.

Do not let the similarity between the appearance and function of medical search sites fool you into thinking they are all alike. They are not. They use different rules and procedures to analyze your queries and decide what results are seen.

If you have tried a query a few times and are not getting the results you are looking for, switch to another search engine. It is natural after searching for awhile to have “favorite” search sites.

In one way this is good, the more you use a particular site the more likely you are to master a particular tool. But, instead of relying on one search site for all your needs, try using several different sites on a regular basis. This way you will get a feel for which ones work best for specific types of searches. Over time, it will become automatic for you to select the “best” search site for each query from among the several that you know well.

Boolean operators (and, or, not) allow you to construct very precise queries that theoretically should give you very precise results. But this is not necessarily the case for two reasons.

First, search sites implement Boolean operators in slightly different ways. If you are going to use Boolean operators, be sure you understand exactly how each site implements them.

Secondly, despite the apparent simplicity, Boolean logic is anything but simple. A misused “not” or a poorly “nested” phrase can lead to wildly inappropriate results. For a good Boolean primer, with helpful illustrations and examples is Boolean Searching on the Internet from the University of Albany Libraries found.

Some search engines ignore certain words. They are never used to find a matching document, despite what amounts to a direct command when you type them into a search form.

These are called “stop words” because the search engine does not “search” when they are found in its index. This is because the stop words are either too common to generate meaningful results, or are parts of speech like adverbs, conjunctions, prepositions, or forms of “be” that mean nothing unless they are part of a phrase with more “important” nouns and verbs. If you use a stop word in a query you may get wildly irrelevant results.

How can you identify stop words? They are listed at the website: Most of the 300 Most Common Words in the English Language found.

Some search engines will tell you when they are ignoring a stop word at the very top of a results page.

Another problem for the net-searcher is whether to use capital letters in a query. Some engines are case sensitive, while others are not. As a rule of thumb, it is best to always use lower case letters when you search This will typically return results that contain both upper and lower case letters.

It is a good idea to bookmark or print out the information you find. It is easy to believe once you have found a page or site using a search engine that you will find it again. It does not work that way.

You may not get the same search results using the same terms if you repeat a search within an hour, let alone days or weeks later. The Web is in constant flux. Thousand of new pages are published to the Web every day, and thousands more moved to new “addresses”, or are removed entirely.

This means a particular “relevance” of a particular document for a specific search query also changes constantly, as it is compared to other documents added to or removed from the search engine index.

If you get stuck, and can not find what you are looking for on the Internet, do not stop looking. Sometimes your best bet for finding information is to log off and take a trip to your local medical library.

Libraries have many resources that are not available on the Internet. And, the librarians are trained experts who are usually more than willing to help you find what you are looking for. Effective searching requires a blend of learned skills, common sense, and a bit of clever intuition.

III. Where to Search For Medical Information

Medical Search Engines/Website Lists

Medical information on the Internet is growing and diversifying. Every month more information is added and it becomes more challenging to sift through the many sites to find the content you are looking for. Traditional search engines do not focus on medical sites, and therefore some very valuable sites are overlooked or not updated into the index.

To date, there is no all-inclusive engine for searching medical sites. Nor is there a single engine that adequately and throughly indexes just the most reputable sites. These are a sampling of sites that will search for and retrieve up-to-date, applicable and current postings from peer-reviewed sources.

National Library of Medicine

The NLM is a very large database and the efficiency of a search can be aided by a review of the MESH (medical subject heading) “trees” at http://www.nlm.nih.gov/mesh/

The mesh trees incorporate the specialized language of the NLM classification system. Failure to use the appropriate language will result in a null or irrelevant search. For example: the phrase kidney calculi should be used instead of kidney stones.

Medline (accessible from various sites)

MEDLINE is the NLM’s premier bibliographic database covering the fields of medicine, nursing, dentistry, veterinary medicine, the health care system, and the preclinical sciences. MEDLINE contains bibliographic citations and author abstracts from more than 4,300 biomedical journals published in the United States and 70 other countries.

The file contains over 11 million citations dating back to the mid-1960’s. Coverage is worldwide, but most records are from English-language sources or have English abstracts. Medline is free, and is accessible from various sites, such as Medscape, Pubmed, and Healthgate.

Pubmed

The PubMed database was developed in conjunction with publishers of biomedical literature as a search tool for accessing literature citations and linking to full-text journal articles at web sites of participating publishers.

Publishers participating in PubMed electronically supply NLM with their citations prior to or at the time of publication. If the publisher has a web site that offers full-text of its journals, PubMed provides links to that site, as well as sites to other biological data, sequence centers, etc.

User registration, a subscription fee, or some other type of fee may be required to access the full-text of articles in some journals.

PubMed provides access to bibliographic information which includes MEDLINE as well as the out-of-scope citations (e.g., articles on plate tectonics or astrophysics) from certain MEDLINE journals, primarily general science and chemistry journals, for which the life sciences articles are indexed for MEDLINE.

Medscape

Medscape is a multi-specialty Web service for clinician and consumers that combines information from journals, medical news providers, medical education programs, and materials created for Medscape. Here you will find a combination of peer-reviewed publications, a free version of drug information via the “First Data Bank File” and free Medline. At the present time there is no fee to set up a user account which gives access to full text articles.

Healthfinder

Healthfinder is a free gateway to reliable consumer health and human services information developed by the U.S. Department of Health and Human Services. healthfinder can lead you to selected online publications, clearinghouses, databases, web sites, support and self-help groups, as well as the government agencies and not-for-profit organizations that produce reliable information for the public.

MD Consult

Founded by leading medical publishers, MD Consult integrates peer-reviewed resources from over 50 publishers, medical societies, and government agencies. From this site you can obtain full text from many respected medical reference books from a variety of specialties, as well as information from medical journals, and MEDLINE.

In addition you can obtain comprehensive USP drug information (beyond the scope of a PDR), and many clinical practice guidelines. This is not a free service, but for a small fee you can have access by the day, month or year. Also there is a free trial membership.

Medical Matrix

Medical Matrix is a source for a wide variety of online resources that include major journals, textbooks, disease and conditions, and patient education. To access this site you must complete an online registration form and fees are charged for some features.

Medical World Search

Medical World Search can aid medical practitioners, researchers, or anyone with basic knowledge of medicine, to formulate an optimally precise query to search the World Wide Web and find exactly the information they need. The major goals of Medical World Search are to provide a search engine that operates over a selection of the most high quality medical sites on the Web and to facilitate searching by using a medical thesaurus that understands medical terminology and can thus search for related terms automatically.

Medical World Search has three components: the Web crawler, the indexer, and the query processor. The Web crawler seeks out medical sites on the World Wide Web, starting from some of the major entry points for clinical medicine, then retrieves them and stores them on Medical World Search’s disk system. The indexer recognizes medical concepts in the pages retrieved by the Web crawler, and generates a large index of all medical concepts and words in the Web pages; this index shows in which pages each concept and word appears. The query processor allows the user to specify his information needs and then attempts to match the query optimally to Web pages using the index generated previously. Results are ranked and returned to the user. There is a small annual fee charged for use of this service.

MD Choice.com

This site is founded by academic physicians. Their goal is to make access to the Internet’s vast health and medical information as efficient and reliable as possible for healthcare professionals as well as consumers. MDchoice.com has combined the content of several award-winning medical websites including NetMedicine.com, Physician’s Choice, and EMBBS.com (The Emergency Medicine and Primary Care Home Page). A panel of board certified physicians in the U.S. evaluate the Web’s medical content.

Guidelines Clearing House

This site is a public resource for evidence-based clinical practice guidelines. NGC is sponsored by the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research) in partnership with the American Medical Association and the American Association of Health Plans. A medical term search will retrieve objective, detailed information on clinical practice guidelines. Results in a search will obtain: structured abstracts (summaries) about the guideline and its development, a utility for comparing attributes of two or more guidelines in a side-by-side comparison, syntheses of guidelines covering similar topics, highlighting areas of similarity and difference, links to full-text guidelines, where available, and/or ordering information for print copies and, annotated bibliographies on guideline development methodology, implementation, and use.

IV. Where to search for information on Pharmaceutical Products

Institute for Safe Medication Practice

The Institute for Safe Medication Practices (ISMP) is a nonprofit organization that works closely with healthcare practitioners and institutions, regulatory agencies, professional organizations and the pharmaceutical industry to provide education about adverse drug events and their prevention. The Institute provides an independent review of medication errors that have been voluntarily submitted by practitioners to a national Medication Errors Reporting Program (MERP) operated by the United States Pharmacopeia (USP) in the USA. Information from the reports may be used by USP to impact on drug standards. All information derived from the MERP is shared with the U.S. Food and Drug Administration ( FDA) and pharmaceutical companies whose products are mentioned in reports.

Lawfirm Websites/Class Actions/Document Vaults

The lawfirm of Feldman & Rifkin, LLP has put together a good site of resources related to class actions and pharmaceutical related litigation resources. Another site link http://www.badproducts.com has a wealth of litigation resources including pleadings and exhibits. You can also do a search of the web and news services by using http://www.google.com for the drug in question.

Formulary Journal

Formulary is a monthly clinical journal for members of Pharmacy and Therapeutic (P & T) Committees (and others charged with drug management responsibilities) at hospitals, HMO’s and other managed care settings, PBM companies, and within the VA system.. This publication contains peer-reviewed clinical articles plus drug-related clinical news, drug-related regulatory news, meeting “pearl” reports, formulary trends, and clinical experience briefs.

The American Society of Health-System Pharmacists

Founded in 1942, this is the premier professional association for hospital and other health-system pharmacists. The Association publishes the IPA database, the American Hospital Formulary Service (the “Red Book”) and the American Journal of Health-System Pharmacy, as well as a number of books and continuing education publications. The site offers timely alerts on medications which have been recalled by the FDA or had warnings issued. The site also offers free MEDLINE access, as well as a directory of headquarters staff and the Association’s publications catalog. Information on purchasing publications is found at this website.

American Association of Pharmaceutical Scientists

The American Association of Pharmaceutical Scientists consists of more than 9,300 pharmaceutical scientists employed in academia, industry, government, and other research institutions worldwide. “Founded in 1986, the goal of AAPS is to improve human health through the development of better pharmaceuticals.” This site provides information about the pharmaceutical science profession, information for members, publications, and links to additional health and pharmaceutical sites.

The American Pharmaceutical Association

The American Pharmaceutical Association (APhA), the national professional society of pharmacists, was founded in 1852 and is the first established and largest professional association of pharmacists in the United States. The more than 50,000 members of APhA include practicing pharmacists, pharmaceutical scientists, pharmacy students, pharmacy technicians, and others interested in advancing the profession. The Association is a leader in providing professional information and education for pharmacists and an advocate for improved health of the American public through the provision of comprehensive pharmaceutical care.

International Society for Pharmaceutical Engineering

ISPE is the Society of choice for more than 13,000 healthcare technology professionals in more than 60 countries… ISPE [is] the leading global source of information, educational services, and forums providing knowledge and practical experience for technical professionals who develop, manufacture, regulate, and support healthcare products. This site includes a calendar of upcoming educational programs; information on ISPE publications; career development and student areas; contact information for affiliates and chapters; and Shared Interest Groups (SIGs) Bulletin Boards, plus information on Good Automated Manufacturing Practices (GAMP), Baseline Pharmaceutical Engineering Guides, and Clinical Trial Materials training tools.

Parenteral Drug Association

PDA is a non-profit professional/technical association whose mission is to support the advancement of pharmaceutical technology by promoting scientifically sound and practical technical information and education for industry and regulatory agencies. PDA is the recognized authoritative voice and leading technical organization in the field of parenteral science and technology. Through the development of technical reports, bulletins and responses to regulatory initiatives. Membership consists of over 9,000 individual and 250 corporate members worldwide. Conferences, meetings and open forums bring together pharmaceutical manufacturers, suppliers, users, academics and regulatory officials to discuss issues of mutual interest.

FDA – Electronic Orange Book – Approved Drug Products with Therapeutic Equivalence Evaluations

At this site you can search for drug information by active ingredient, drug applicant holder, proprietary name, or application number. If you have the trade name, search the Electronic Orange Book Rx or OTC section using the Proprietary Name search. This determines the ingredient(s). Then use the Ingredient Search for all approved products that contain the ingredient(s). The resulting list will provide approved products by dosage form and route. For each dosage form; route grouping, there will be a Reference Listed Drug (RLD) that is the innovator product. One or more strengths will have a Yes RLD. If there are approved generic products of another firm, the RLD will be No and all the products within the dosage form; route grouping will have a therapeutic Equivalence Code (TE Code). Products that have been discontinued are in the Discontinued Section and do not RLD or TE Codes. The OTC Section products are not evaluated for therapeutic Equivalence.

Information not found here can be requested from the FDA by going to CDER Freedom of Information Office

Pharmaceutical Research and Manufacturers of America

The Pharmaceutical Research and Manufacturers of America (PhRMA) represents the country’s leading research-based pharmaceutical and biotechnology companies. You can search medication/pharmaceuticals in development by disease, drug name, or company name.

Biotechnology Information Directory

This directory contains well over 1500 URLs of companies, research institutes, universities, sources of information and other directories specific to biotechnology, pharmaceutical development and related fields. It places emphasis on product development and the delivery of products and services. It includes a listing of pharmaceutical companies and their associated websites, as well as a link to the European mirror site.

Hardin Meta Directory of Internet Health Sources: Pharmacy and Pharmacology

As a “metadirectory” this site provides a “directory of directories” on a variety of medical topics. The section on pharmacy and pharmacology provides links to 20 different directories on the World Wide Web.

Virtual Library: Pharmacy

This general site also includes links to information on pharmacokinetics and pharmaceutical chemistry. Included are links to schools of pharmacy throughout the world, community pharmacy web pages, and job information for pharmacists. Maintained by the University of Oklahoma College of Pharmacy.

PharmWeb

This site is maintained at the University of Manchester (England), and is “mirrored” by over a half-dozen sites throughout the world. It includes extensive links to Internet resources of interest to pharmacists and maintains numerous discussion groups.

University of Sydney Department of Pharmacy — Pharmacy Internet Guide

This site includes a thorough and logically organized guide with links to pharmacy resources on the Internet. The guide includes an extensive list of email discussion groups and electronic journals of interest to pharmacists.

FDA Bulletin Board/World Wide Web site

Includes FDA Federal Register Notices, Drug & Device Approvals, agency press releases, FDA Consumer Magazine. A search form is available for searching the FDA web site for information on a specific topic or drug.

U.S. Department of Health & Human Services

The DHHS is the parent agency of the Health Care Financing Administration MedicareMedicaid), Food & Drug Administration, Centers for Disease Control, Agency for Health Care Policy & Research, Agency for Toxic Substances & Disease Registry and others. Links to the agency web sites, as well as grant, research and policy information are available from this central site.

National Institutes of Health

Links to CancerNet PDQ Drug Information, the full-text of Clinical Practice Guidelines, grant information, and NIH sponsored research in progress.

National Library of Medicine

The National Library of Medicine (NLM) provides no-cost access to MEDLINE, a database which provides citations to the primary biomedical literature. MEDLINE can be searched via the World Wide Web from this website using either NLM’s “Internet Grateful Med” search engine, or the “Pub Med” search engine. Pub Med also includes links to a small number of full-text articles available on the World Wide Web.

V. General Information Searching

Search engines rely on computer programs called spiders or robots to crawl the Web and log the words on each page. With a search engine, keywords related to a topic are typed into a search “box.” The search engine scans its database and returns a file with links to websites containing the word or words specified. Because these databases are very large, search engines often return thousands of results. Without search strategies or techniques, finding what you need can be like finding a needle in a haystack.

General search engines are good for finding information and sites on a specific topic. The search results generally will contain many irrelevant sites, and you will need to “sift” through your results to find information that is useful.

There are many tutorials for web searching techniques on the Internet. One particularly good tutorial, which you may download and print for reference is Bright Planet’s “Deep Content” tutorial.

This is an in-depth Web searching tutorial, organized to proceed from the basics to more advanced topics. It has 12 parts containing over 60 topics.

Listed below are some of the more popular general search engines.

VI. General Information Search Engines/Website Lists

Google

Google consistently turns up high-quality, highly relevant results. Google does well on specific queries such as American Pediatric Neurological Organizations, and broad-topic searches, such as Medical Professional Organizations. It’s also great at targeting a specific home page. Depending on your query, you may get stock quotes, or related news stories for example. My favorite feature is Google’s ability to view cached copies of results pages. When the page you want to access is no longer live, you can view a cached copy of the way it looked the last time Google crawled it. Google offers only basic query customization features, including phrase searching and foreign-language filtering. You can use plus or minus signs to include or exclude keywords, or you can head to the Advanced Search page for drop-down pick lists to construct complex searches. There is a similar page” feature as well as a translator for foreign language websites.

About

About.com uses “professional Guides” to research and collect over a million useful sites in over 700 topic areas. About.com is a great place to start a web inquiry as long as you’re not looking for anything to specific. Think of it as a resource library for popular subjects. Uses Sprinks (powered by the competent Inktomi) as a default search engine if it can’t find your query at about.com.

Dogpile

Dogpile uses a different concept to search the Internet than most other general content search engine. Rather than maintaining its own database of Web site addresses and their contents, Dogpile searches the databases maintained by the other general content search engines, such as Google, Ask, MSN-Search and Yahoo Search, as well as databases maintained by Usenet newsgroups, ftp sites, newswires, and business news sources.

Dogpile begins by searching the larger general content search engine databases and general purpose directories, and then gradually moves through smaller, more specific search engines. The user is permitted to alter the order of search, however.

Open Directory Project

The goal of this new engine is to produce the most comprehensive directory of the web, Similar to Yahoo, listings are organized by category and reviewed by editors. The ODP is a Web directory, not a search engine. Although they do offer a search query, the purpose of the ODP is to list and categorize web sites. They do not rank, promote or optimize sites for search engines. The ODP is simply a data provider.

WebFerret

WebFerret is free software that searches the internet for you. (This type of program is called a “bot.”) WebFerret uses several search engines, looking as deeply as you like to “ferret” out the pages you’re interested in. You can search the entire text of pages, their titles and descriptions, just their titles, or even just their URLs. What search features you select determines how fast WebFerret works.

In addition, WebFerret will eliminate duplicates by URL, title, or host. WebFerret will list the pages it finds by relevance, title, address or source, then you can save your search as WebFerret search results (an ASCII file or HTML). Since WebFerret is a small program, so it can work in the background.

VII. Summary

The Internet continually offers more opportunities to find information on medical and related topics. However, with the expanding resources comes a larger challenge for net-researchers to find the information they are seeking. The more experience the researcher gains the more proficient they become in finding pertinent data.

Janabeth F. Taylor, R.N., R.N.C. has a degree in Nursing from Oklahoma State University and a Litigation Paralegal Certificate from the University of Oklahoma Law Center. She was a nursing instructor for ten years and has been a medical legal consultant since 1990.

The American Trial LawyerÕs Association (ATLA) named Mrs. Taylor PARALEGAL OF THE YEAR 2002.

Mrs. Taylor is currently President/Owner of Attorney’s Medical Services, Inc. in Corpus Christ, TX. She provides litigation support for attorneys across the United States and specializes in case reviews and Internet information resources.

Drug Information Resources: Researching Medications

When investigating a claim for injury related to a pharmaceutical product there are many resources available via the Internet. A general search engine such as Google (www.google.com) will provide general information concerning litigation involving these products. By selecting the advanced Google search option for news services you can find information provided by popular newswire services. When performing a general search for the drug or product by name you can find lawfirm websites, medical information and a variety of resources that are valuable in researching your client’s claim. Some of the professional and peer reviewed resources available online are discussed below.

International and National Pharmacopoeias

In the so-called pharmacopoeias the respective governments of a state issue obligatory regulations for the quality of the active ingredients and also the excipients of a medicine. Consequently pharmacopoeias represent important prescriptions for a chemist in his pharmacy and the researching pharmaceutical industry, but also for universities and regulatory authorities all over the world.

Caused by the rapidly increasing globalization we seeourselves again and again confronted with the need for pharmaceutical regulations of other countries and other parts of the world. However, once in this situation we often do not know where we can obtain these information. One place found on the web where information on purchasing pharmacopeias from European, middle eastern, and oriental countries is found.

The United States Pharmacopeia

What is the U.S. Pharmacopeia?

The United States Pharmacopeia (USP) is a non-government organization that promotes the public health by establishing state-of-the-art standards to ensure the quality of medicines and other health care technologies. These standards are developed by a unique process of public involvement and are accepted worldwide. In addition to standards development, USP’s other public health programs focus on promoting optimal health care delivery and are listed below. USP is a not-for-profit organization that achieves its goals through the contributions of volunteers representing pharmacy, medicine, and other health care professions, as well as science, academia, the U.S. government, the pharmaceutical industry, and consumer organizations.

USP works closely with the Food and Drug Administration (FDA), the pharmaceutical industry, and the health professions, to establish authoritative drug standards. These standards are enforceable by the FDA and the governments of other countries, and are recognized worldwide as the hallmark of quality. More than 3,800 standards monographs are published in the U.S. Pharmacopeia (USP) and the National Formulary (NF), the official drug standards compendia. USP also provides about 1,300 premier chemical Reference Standards to carry out the tests specified in USPBNF.

USP believes that the sharing of field experiences and concerns among health care professionals is important to reducing medication errors and providing safer, better quality health care. It therefore operates programs for health care professionals to report problems encountered during clinical practice. Reports received are used to build comprehensive information databases, improve USP’s drug standards, and provide feedback to reporting professionals, product manufacturers, and regulatory agencies. By sharing these experiences, pharmacists, nurses, physicians, and students can contribute to improved patient safety and to the development of valuable educational services for the prevention of future errors.

USP reviews each report for health hazards and forwards all information to the FDA and the product manufacturer. USP will act as your liaison with the FDA and the manufacturer should you wish to submit a report anonymously. The MER Program is presented in cooperation with the Institute for Safe Medication Practices.

What does USP do?

USP’s activities and initiatives revolve around four public health programs:

Standards Establishing standards is a core USP activity. Currently, USP provides standards for more than 3,400 prescription and non-prescription drugs, nutritional and dietary supplements, veterinary drug standards, and health care products. These standards are published in the United States Pharmacopeia and the National Formulary (USP-NF), which are officially recognized in the Federal Food, Drug, and Cosmetic Act (21 U.S.C. ‘ 321 et seq.). USP also produces Reference Standards, which are an integral part of USP’s standards program. In addition, USP offers a Pharmacopeial Education program that provides continuing educational courses for professionals working in the pharmaceutical industryChelping those who use the USP-NF better understand pharmacopeial processes, standards, and tests and methods.

Dietary Supplement Verification Program (DSVP). USP has developed this program in response to the increasing concerns expressed about the quality of dietary supplements in the marketplace. Through compliance testing and document review, adherence to good manufacturing principles, and post-marketing surveillance, DSVP is designed to help assure that dietary supplement products contain the declared ingredients in the declared quantities. Further information about DSVP is at www.usp-dsvp.org.

Health Care Information. In association with MICROMEDEX (a division of Thomson Publishing), USP provides oversight and approval of drug information content in the USP DI7 database, which covers nearly all medicines in the U.S. and Canada. USP contributes “value-added” information about new and off-label uses of drugs. USP’s Health Care Information program also consists of several global initiatives. USP was awarded several grants by the United States Agency for International Development’s (USAID) Center for Population, Health and Nutrition (PHN). Currently, USAID is supporting the USP Drug Quality and Information (USPDQI) program, which funds programs in Nepal, Russia, Mozambique, and the Mekong Delta region.

Patient Safety. USP operates two medication error reporting, tracking, and analysis programs: the Medication Errors Reporting (MER) Program (operated in collaboration with the Institute for Safe Medication Practices) and the MedMARxSMProgram. MedMARx is an Internet-accessible database for hospitals to report and track medication errors anonymously.

Drugs Facts and Comparisons

Published by Lippincott Williams & Wilkins
The most up-to-date, comprehensive drug information source available. Drug Facts and Comparisons contains more than 22,000 Rx and almost 6,000 OTC drugs, grouped by therapeutic category for ease of comparison. Orphan and investigational drugs are included. Drug Facts and Comparisons also contains thousands of charts and tables. Drug Facts and Comparisons is updated monthly and is ideal to keep current on all changes in the drug industry.

Stanford SKOLAR MD

Stanford SKOLAR MD is a Web-based medical knowledge service for physicians. SKOLAR was developed and is used at the Stanford University School of Medicine for the purpose of bringing up-to-date medical information to the clinician. Content is continuously updated, reviewed and approved by a content committee of respected Stanford and community physicians. Physicians can use AMA-approved SKOLAR MD to research a patient problem or condition and earn Category 1 CME credit for the time spent improving your patient’s care. SKOLAR is the first AMA-approved system that allows physicians to earn CME credit for independently directed learning.

Enter a key word or phrase and SKOLAR searches across multiple resources that you can select: textbooks, drug databases, bibliographies, guidelines, full text journals, evidence based medicine and patient education material. You can even do a ICDM Code look up with your search. Drug database information is displayed in a format that highlights the most commonly sought after information and simplifies navigation within the material. For a demonstration of all the features you can go to: http://www.skolar.com/demonstrations.html To sign up for a free 10 trial period go to: http://www.skolar.com/index.html

Institute for Safe Medication Practice

The Institute for Safe Medication Practices (ISMP) is a nonprofit organization that works closely with healthcare practitioners and institutions, regulatory agencies, professional organizations and the pharmaceutical industry to provide education about adverse drug events and their prevention. The Institute provides an independent review of medication errors that have been voluntarily submitted by practitioners to a national Medication Errors Reporting Program (MERP) operated by the United States Pharmacopeia (USP) in the USA. Information from the reports may be used by USP to impact on drug standards. All information derived from the MERP is shared with the U.S. Food and Drug Administration ( FDA) and pharmaceutical companies whose products are mentioned in reports.

Online Resources

Lawfirm Websites/Class Actions/Document Vaults

The lawfirm of Feldman & Rifkin, LLP has put together a good site of resources related to class actions and pharmaceutical related litigation resources. Also another site link www.badproducts.com has a wealth of litigation resources including pleadings and exhibits.

Formulary Journal

Formulary is a monthly clinical journal for members of Pharmacy and Therapeutic (P & T) Committees (and others charged with drug management responsibilities) at hospitals, hmo’s and other managed care settings, PBM companies, and within the VA system.. This publication contains peer-reviewed clinical articles plus drug-related clinical news, drug-related regulatory news, meeting “pearl” reports, formulary trends, and clinical experience briefs.

The American Society of Health-System Pharmacists

Founded in 1942, this is the premier professional association for hospital and other health-system pharmacists. The Association publishes the IPA database, the American Hospital Formulary Service (the “Red Book”) and the American Journal of Health-System Pharmacy, as well as a number of books and continuing education publications. The site offers timely alerts on medications which have been recalled by the FDA or had warnings issued. The site also offers free MEDLINE access, as well as a directory of headquarters staff and the Association’s publications catalog. Information on purchasing publications is found at this website.

American Association of Pharmaceutical Scientists

The American Association of Pharmaceutical Scientists consists of more than 9,300 pharmaceutical scientists employed in academia, industry, government, and other research institutions worldwide. “Founded in 1986, the goal of AAPS is to improve human health through the development of better pharmaceuticals.” This site provides information about the pharmaceutical science profession, information for members, publications, and links to additional health and pharmaceutical sites.

The American Pharmaceutical Association

The American Pharmaceutical Association (APhA), the national professional society of pharmacists, was founded in 1852 and is the first established and largest professional association of pharmacists in the United States. The more than 50,000 members of APhA include practicing pharmacists, pharmaceutical scientists, pharmacy students, pharmacy technicians, and others interested in advancing the profession. The Association is a leader in providing professional information and education for pharmacists and an advocate for improved health of the American public through the provision of comprehensive pharmaceutical care.

International Society for Pharmaceutical Engineering

ISPE is the Society of choice for more than 13,000 healthcare technology professionals in more than 60 countries… ISPE [is] the leading global source of information, educational services, and forums providing knowledge and practical experience for technical professionals who develop, manufacture, regulate, and support healthcare products. This site includes a calendar of upcoming educational programs; information on ISPE publications; career development and student areas; contact information for affiliates and chapters; and Shared Interest Groups (SIGs) Bulletin Boards, plus information on Good Automated Manufacturing Practices (GAMP), Baseline Pharmaceutical Engineering Guides, and Clinical Trial Materials training tools.

Parenteral Drug Association

PDA is a non-profit professional/technical association whose mission is to support the advancement of pharmaceutical technology by promoting scientifically sound and practical technical information and education for industry and regulatory agencies. PDA is the recognized authoritative voice and leading technical organization in the field of parenteral science and technology. Through the development of technical reports, bulletins and responses to regulatory initiatives. Membership consists of over 9,000 individual and 250 corporate members worldwide. Conferences, meetings and open forums bring together pharmaceutical manufacturers, suppliers, users, academics and regulatory officials to discuss issues of mutual interest.

FDA-Electronic Orange Book-Approved Drug Products with Therapeutic Equivalence Evaluations

At this site you can search for drug information by active ingredient, drug applicant holder, proprietary name, or application number. If you have the trade name, search the Electronic Orange Book Rx or OTC section using the Proprietary Name search. This determines the ingredient(s). Then use the Ingredient Search for all approved products that contain the ingredient(s). The resulting list will provide approved products by dosage form and route. For each dosage form; route grouping, there will be a Reference Listed Drug (RLD) that is the innovator product. One or more strengths will have a Yes RLD. If there are approved generic products of another firm, the RLD will be No and all the products within the dosage form; route grouping will have a therapeutic Equivalence Code (TE Code). Products that have been discontinued are in the Discontinued Section and do not RLD or TE Codes. The OTC Section products are not evaluated for therapeutic Equivalence.

Information not found here can be requested from the FDA by going to CDER Freedom of Information Office 

Pharmaceutical Research and Manufacturers of America

The Pharmaceutical Research and Manufacturers of America (PhRMA) represents the country’s leading research-based pharmaceutical and biotechnology companies. You can search medication/pharmaceuticals in development by disease, drug name, or company name.

Biotechnology Information Directory

This directory contains well over 1500 URLs of companies, research institutes, universities, sources of information and other directories specific to biotechnology, pharmaceutical development and related fields. It places emphasis on product development and the delivery of products and services. It includes a listing of pharmaceutical companies and their associated websites, as well as a link to the European mirror site.

Hardin Meta Directory of Internet Health Sources: Pharmacy and Pharmacology

As a “metadirectory” this site provides a “directory of directories” on a variety of medical topics. The section on pharmacy and pharmacology provides links to 20 different directories on the World Wide Web.

Virtual Library: Pharmacy

This general site also includes links to information on pharmacokinetics and pharmaceutical chemistry. Included are links to schools of pharmacy throughout the world, community pharmacy webpages, and job information for pharmacists. Maintained by the University of Oklahoma College of Pharmacy.

PharmWeb

This site is maintained at the University of Manchester (England), and is “mirrored” by over a half-dozen sites throughout the world. It includes extensive links to Internet resources of interest to pharmacists and maintains numerous discussion groups.

University of Sydney Department of Pharmacy – Pharmacy Internet Guide

This site includes a thorough and logically organized guide with links to pharmacy resources on the Internet. The guide includes an extensive list of email discussion groups and electronic journals of interest to pharmacists.

FDA Bulletin Board/World Wide Web Site

Includes FDA Federal Register Notices, Drug & Device Approvals, agency press releases, FDA Consumer Magazine. A search form is available for searching the FDA web site for information on a specific topic or drug.

U.S. Department of Health & Human Services

The DHHS is the parent agency of the Health Care Financing Administration MedicareMedicaid), Food & Drug Administration, Centers for Disease Control, Agency for Health Care Policy & Research, Agency for Toxic Substances & Disease Registry and others. Links to the agency web sites, as well as grant, research and policy information are available from this central site.

National Institutes of Health

Links to CancerNet PDQ Drug Information, the full-text of Clinical Practice Guidelines, grant information, and NIH sponsored research in progress.

National Library of Medicine

The National Library of Medicine (NLM) provides no-cost access to MEDLINE, a database which provides citations to the primary biomedical literature. MEDLINE can be searched via the World Wide Web from this website using either NLM’s “Internet Grateful Med” search engine, or the “Pub Med” search engine. Pub Med also includes links to a small number of full-text articles available on the World Wide Web.

Preparing for the defense medical expert’s deposition

Conduct in-depth research online and through formal discovery before deposing your opponent’s witnesses to expose weaknesses and bias in their testimony.

Medical negligence cases can be among the most complex to try, and preparing for them can require an enormous amount of time and effort. By gathering information about the defense’s medical expert before taking his or her deposition, you can make the best use of the time you spend asking questions.

A combination of independent research, most of which you can conduct online, and formal discovery requests will provide the best background for deposition.

Go online for information

Basic facts about a medical expert, such as academic training and credentials, articles and publications, ethical guidelines to be met, and disciplinary actions and litigation, can be reaped from the Internet. Some general information will even appear in a Google search (www.google.com).

You should also check the professional and litigation history submitted by the adverse expert witness against databases of expert testimony and other information. You may discover omissions or misinformation.

The ATLA Exchange (www.exchange.atla.org), the association’s research and litigation support service, has databases containing depositions, court documents, case abstracts, and more. Association members who are plaintiff lawyers can search the Web site for free, and several pricing plans are available for obtaining documents.

TrialSmith (www.trialsmith.com), formerly DepoConnect, is another online databank. A single search can provide information from depositions and court testimony, messages from list servers across the country, medical database searches, and public records. The service offers several subscription plans.

The National Association of State Jury Verdict Publishers (www.juryverdicts.com) publishes jury verdict summaries that contain detailed litigation information collected directly from the attorneys who tried the cases. The Web site also holds an alphabetical directory of expert witnesses containing names, areas of expertise, and publications in which an expert has been referenced. Information from the “Cases Testified” section of the site can be used to select or challenge an expert.

Although you must subscribe to use Westlaw and Lexis, you can search them for testimonial history information in any state court, as well as the federal courts. For example, you might find that an expert you are preparing to depose failed a Daubert challenge in the same area in which the defense is offering his or her testimony in your case.

Contact state trial lawyer associations for information about experts. Many of these groups have their own databases of expert information. A listing by state, with links to association home pages and phone numbers, can be found at www.drugintel.com/public/state_trial_lawyers_associations.htm.

What to look for

You must have at least the defense expert’s curriculum vitae for your research before the deposition. Draw up a list of other information to gather, and consider submitting it as a formal document request; that will avoid the argument that you have not given the defendant reasonable notice for document production. Make sure you formally request copies of all documents the defense has provided to the expert for review, and ask that they be produced for review at the deposition.

To be thoroughly prepared to question the adverse witness, gather information about the expert in the following areas.

Academic training and credentials. Verifying an expert’s qualifications is an essential first step.

  • Subpoena the expert’s transcripts. You should get transcripts from every college or university where he or she received medical training.

Consider the timing of this request, since you may want to allow the expert to commit to a position regarding academic performance. If you obtain the actual transcripts and learn that the expert has misrepresented his or her grades or accomplishments, then you have the ability to impeach the expert at trial. One attorney using this tactic said he learned that a defense expert had attended school by mail.

  • Search for board certifications. The American Board of Medical Specialties (www.abms.org) has a database that you can search by physician name. Registration is free.

General information databases will not provide the number of attempts a physician has made to receive board certifications. However, individual Web sites for medical specialties often do provide more complete information, as well as practice standards and guidelines. For example, the Web site of the American Board of Psychiatry and Neurology (www.abpn.com) walks a subscriber through the process for requesting board status information and provides a request form, which must be submitted in writing and accompanied by a $35 fee.

  • Request written verification of the expert’s license. Contact the medical boards for the states in which the expert is licensed. The Federation of State Medical Boards lists state boards, with contact information, at www.fsmb.org.
  • Verify that your adverse expert is not spreading false medical information. Visit www.quackwatch.org, a database that contains exhaustive lists of “quacks,” FDA warning letters, regulatory actions, and “nonrecommended” sources of health advice.

Articles. Look for articles written or cowritten by the defense expert in your case’s subject area. Articles that are not referenced on the expert’s curriculum vitae often can be obtained on the Internet.

  • The PubMed database (www.ncbi.nlm.nih.gov/PubMed), which is part of the National Library of Medicine, was designed by publishers of biomedical literature as an access and reference tool. It contains citations and provides links to full-text journal articles on the Web sites of participating publishers. Some publishers even supply their citations electronically prior to publication. Note that some journals require user registration and a fee to access the full text of their articles.
  • The MD Consult database (www.mdconsult.com), founded by a group of medical publishers including Mosby and W.B. Saunders, integrates peer-reviewed resources from more than 75 publishers, medical societies, and government agencies.

The Web site offers full-text articles from 40 respected medical reference books covering a variety of specialties, 50 medical journals, and Medline. The database also holds more than 1,000 clinical practice guidelines, as well as comprehensive drug information from United States Pharmacopeia that goes beyond the scope of the information provided in the Physician’s Desk Reference.

The service charges an access fee of $9.95 a day, $24.95 a month, or $219.95 a year. A free 30-day trial membership is available.

Ethical standards. Many professional organizations have ethical guidelines that include standards for testimonial opinions. Knowing these standards can help the plaintiff lawyer establish a defense expert’s lack of knowledge, especially if he or she is unaware that the standards exist. An expert may also ignore or refute the standards in order to support the defendant.

  • The American Academy of Forensic Sciences (www.aafs.org) includes a written code of ethics in its bylaws. The code prohibits making “any material misrepresentation of education” or “data upon which an expert opinion or conclusion is based.”1

• The American College of Emergency Physicians (www.acep.org) has established guidelines for expert witnesses and an “expert witness reaffirmation” statement.

The guidelines require that an expert witness be willing to submit his or her deposition testimony to the organization for peer review. False, fraudulent, or misleading testimony can expose the physician to disciplinary action by the college. In 1997, the college adopted a code of ethics, which is posted on its Web site.2

• The American Medical Association (www.ama-assn.org) also places its code of ethics on the Internet. The code contains a “fundamental ethical requirement that a physician should at all times deal honestly and openly with patients. Patients have a right to know their past and present medical status and to be free of any mistaken beliefs concerning their conditions.”3

The expert’s opinion of the defendant’s care may not support these ethics, or you may discover that the defendant doctor did not meet his or her duty to inform patients.

• The American Academy of Neurology (www.aan.com) posts not only a code of professional conduct, but also a list of position statements that include “qualifications and guidelines” for members serving as expert witnesses.

Disciplinary actions and litigation. Occasionally, you find that the defense’s medical expert has a history of personal or professional litigation that makes the defense lawyer who retained the expert witness uncomfortable. This information can, of course, be used to attack the witness’s credibility.

In order to find information on legal actions, search dockets where the expert is located. Many state and county court clerks’ offices make their docket archives available online. A list of electronically accessible clerks’ offices can be found. Search both the criminal and civil dockets, using the expert’s name as both a plaintiff and a defendant.

Also, check the expert’s disciplinary record. Questionable Doctors (www.questionabledoctors.org/intro.cfm) is a comprehensive, publicly available databank of doctors who have been disciplined by state medical boards and federal agencies in the past 10 years. It contains data on disciplinary actions for medical incompetence, wrongful prescribing of drugs, sexual misconduct, criminal convictions, ethical lapses, and other offenses.

Another searchable database, AIM/DocFinder (www.docboard.org/doc finder.html), contains licensing background and disciplinary information for physicians and other health care practitioners.

Formal discovery requests

After you have exhausted all possible sources of information about the opponent’s expert, draft your interrogatories.

Use form interrogatories following state rules and Federal Rule of Civil Procedure 26(a)(2) to require the defense to set forth its expert’s generalized opinions and the minimal information going to bias. The federal rule requires disclosure of the expert’s opinion in a written report prepared and signed by the witness.

In addition, many states allow discovery of financial earnings from litigation, the relationship between the defense law firm and expert witness, and the relationship between the insurer and expert, even if the defendant is the insured.

Some states have allowed specific inquiry into the division of expert witness litigation earnings. Others have not. For example, the Pennsylvania Superior Court has upheld objections to questions regarding how often the expert witness was retained to testify, the amount he or she was paid in other cases, and whether the majority of the expert’s professional time was spent “rendering assistance to lawyers.”4

More commonly, however, state courts permit inquiry at deposition and trial into the amount of compensation an expert derives from testifying.5 A Florida court ruled that when this type of information is sought, courts should weigh the interests of the cross-examining party in disclosing bias and generally allow the discovery.6

The Kentucky Supreme Court has held that an expert physician’s annual income related to litigation work, and the percentage of his or her general practice that this income constitutes, is discoverable and admissible to show bias.7

In another case, a Florida appeals court removed any doubt about whether a plaintiff could obtain information about an expert witness’s relationship to an insurer, even when the insurer is not a party to the lawsuit. The court recognized that the insurer, in providing a defense for its insured, acts as the insured’s agent, as does the defense attorney. Thus, the relationship between the insurer and the expert witness is discoverable.8

In South Carolina, under the authority of Yoho v. Thompson, a party may obtain 1099 tax forms, past expert reports, and documentation pertaining to the cases for which an expert has been retained.9 An expert who does not provide the discovery can be stricken. Yoho was reversed, but the state supreme court upheld the “substantial connection” analysis and allowed evidence to show the expert doctor’s relationship with the underinsured motorist’s carrier and the doctor’s possible bias in favor of the insurer.10

To show bias, New Mexico and Virginia courts have also admitted evidence of an expert’s compensation paid by the defendant’s liability carrier.11 In Sawyer v. Comerci, for example, the expert witness had testified for the insurer in the past, specifically for the defendant doctor. The court found that there was a “substantial connection” between the witness and the insurer.12

In contrast, Michigan courts have not allowed proof of insurance company payments to be directly introduced into evidence. However, those courts have admitted evidence of the number of cases in which the expert was consulted, the fact that consultations were all for the defense, and the fact that the expert had been previously hired by the defense firm and other defense firms in the state.13

In some states, the expert must provide a testimonial history for the last three years if he or she wishes to testify in court.14 Unfortunately, many defendants respond that they don’t have or don’t know this history, and many judges are reluctant to seriously consider striking an expert for not providing it until you have exhausted other attempts to obtain it. You may be able to get a testimonial history by deposing the custodian of expert witness’s records, either orally or in writing.

Researching the defense medical expert before you take his or her deposition will focus your line of questioning and help you uncover areas of potential bias in favor of the defendant. Keep in mind that the defense expert is not independent. Demonstrating bias, whether it is financial or based on loyalty to your opponent, helps the jury remember to be skeptical of the testimony.