Development of a clinical information tool for the electronic medical record: a case study

Question:

What is the process of developing a clinical information tool to be embedded in the electronic health record of a very large and diverse academic medical center?

Setting:

The development took place at the University of Pittsburgh Health Sciences Library System.

Method:

The clinical information tool developed is a search box with subject tabs to provide quick access to designated full-text information resources. Each subject tab offers a federated search of a different pool of resources. Search results are organized “on the fly” into meaningful categories using clustering technology and are directly accessible from the results page.

Results:

After more than a year of discussion and planning, a clinical information tool was embedded in the academic medical center''s electronic health record.

Conclusion:

The library successfully developed a clinical information tool, called Clinical-e, for use at the point of care. Future development will refine the tool and evaluate its impact and effectiveness.     

The value of library and information services in patient care: results of a multisite study

Objective:

The research conducted a large-scale, multisite study on the value and impact of library and information services on patient care.

Methods:

The study used: (1) 2 initial focus groups of librarians; (2) a web-based survey of physicians, residents, and nurses at 56 library sites serving 118 hospitals; and (3) 24 follow-up telephone interviews. Survey respondents were asked to base their responses on a recent incident in which they had sought information for patient care.

Results:

Of the 16,122 survey respondents, 3/4 said that they had definitely or probably handled aspects of the patient care situation differently as a result of the information. Among the reported changes were advice given to the patient (48%), diagnosis (25%), and choice of drugs (33%), other treatment (31%), and tests (23%). Almost all of the respondents (95%) said the information resulted in a better informed clinical decision. Respondents reported that the information allowed them to avoid the following adverse events: patient misunderstanding of the disease (23%), additional tests (19%), misdiagnosis (13%), adverse drug reactions (13%), medication errors (12%), and patient mortality (6%).

Conclusions:

Library and information resources were perceived as valuable, and the information obtained was seen as having an impact on patient care.

Highlights

• Library and information resources were perceived as valuable, and the information obtained was seen as having an impact on patient care.
• Electronic access to information resources from multiple locations has increased the ability of health professionals to use these resources for improved patient care.
• The roles of librarians are diversifying to include management of electronic resources, user instruction and support, specialized research and clinical information search services, and involvement in institution-level quality improvement.
• It is possible to conduct a large-scale, multisite study on the value and impact of library services on patient care.

Implications

• Ongoing studies of the value and impact of library and information resources will be important for advocacy and quality improvement.
• Community-Based Participative Research methods hold promise as a way of ensuring the relevance of future research.

     

A case study: planning a statewide information resource for health professionals: an evidence-based approach

Question:

What is the best approach for implementing a statewide electronic health library (eHL) to serve all health professionals in Minnesota?

Setting:

The research took place at the University of Minnesota Health Sciences Libraries.

Methods:

In January 2008, the authors began planning a statewide eHL for health professionals following the five-step process for evidence-based librarianship: formulating the question, finding the best evidence, appraising the evidence, assessing costs and benefits, and evaluating the effectiveness of resulting actions.

Main Results:

The authors identified best practices for developing a statewide eHL for health professionals relating to audience or population served, information resources, technology and access, funding model, and implementation and sustainability. They were compared to the mission of the eHL project to drive strategic directions by developing recommendations.

Conclusion:

EBL can guide the planning process for a statewide eHL, but findings must be tailored to the local environment to address information needs and ensure long-term sustainability.     

Rural providers' access to online resources: a randomized controlled trial

Objective

The research determined the usage and satisfaction levels with one of two point-of-care (PoC) resources among health care providers in a rural state.

Methods

In this randomized controlled trial, twenty-eight health care providers in rural areas were stratified by occupation and region, then randomized into either the DynaMed or the AccessMedicine study arm. Study participants were physicians, physician assistants, and nurses. A pre- and post-study survey measured participants'' attitudes toward different information resources and their information-seeking activities. Medical student investigators provided training and technical support for participants. Data analyses consisted of analysis of variance (ANOVA), paired t tests, and Cohen''s d statistic to compare pre- and post-study effects sizes.

Results

Participants in both the DynaMed and the AccessMedicine arms of the study reported increased satisfaction with their respective PoC resource, as expected. Participants in both arms also reported that they saved time in finding needed information. At baseline, both arms reported too little information available, which increased to “about right amounts of information” at the completion of the study. DynaMed users reported a Cohen''s d increase of +1.50 compared to AccessMedicine users'' reported use of 0.82. DynaMed users reported d2 satisfaction increases of 9.48 versus AccessMedicine satisfaction increases of 0.59 using a Cohen''s d.

Conclusion

Participants in the DynaMed arm of the study used this clinically oriented PoC more heavily than the users of the textbook-based AccessMedicine. In terms of user satisfaction, DynaMed users reported higher levels of satisfaction than the users of AccessMedicine.Keywords and Medical Subject Headings (MeSH) Clinical Decision Support Systems, Computer-Assisted Decision Making, Decision Making, Evidence-Based Library and Information Practice, Evidence-Based Practice, Health Status Disparities, Health Care Disparities, Information Divide, Information-Seeking Behavior, Medically Underserved Area, Nurse Practitioners, Nurses, Physician Assistants, Physicians, Public Health Nurses, Randomized Controlled Trial as Topic, Service Learning, Vulnerable PopulationsHealth care practitioners regularly seek to incorporate valid information into their evidence-based decisions. Electronic information resources now provide easy access to current health information and summarized forms of evidence to support clinical decision making.

Access effects on health care

Health care providers who are affiliated with well-funded institutions benefit from access to a variety of high-quality information resources to support their evidence-based practices. Practitioners who are not affiliated with academic health sciences centers rarely have access to these same resources due to prohibitively high licensing costs. Ely et al. report that not having access to easy-to-use, high-quality, current information can negatively affect sound clinical decision making. [1].Patients in Isaac et al.''s study who were admitted to hospitals that had access to an electronic evidence-based resource experienced reduced length of stay and lower risk-adjusted mortality rates for prespecified conditions [2]. That study was validated on a broader scale by a multicenter investigation on the utilization of information resources by practitioners [3].Primary health care practitioners who are not affiliated with academic health sciences centers, particularly those who practice in rural or remote areas, often articulate the need for increased access to health information resources. The authors'' literature search and review of 114 of the most relevant research articles about the information needs and information-seeking behavior of health care practitioners suggested that these professionals most value speed and accuracy. For example, they likely would prefer to use point-of-care (PoC) resources for quickly and accurately answering their clinical questions.

Desirability of point of care

PoC resources quickly guide physicians through the diagnosis, treatment, and management of commonly encountered clinical conditions. PoC resources can present compilations of highly authoritative, often evidence-based, information. Physicians can answer more questions and revise clinical decisions more often using these PoC resources [4]. Meanwhile, many health care practitioners still rely on textbooks familiar to them from their professional training programs, despite their potentially dated contents [5–14].

Limited access in rural New Mexico

A randomized controlled trial involving public health practitioners across the rural state of New Mexico reported many barriers in accessing valued information resources [15, 16]. In another study, researchers in New Mexico set out to determine and analyze information needs of health care practitioners who were not affiliated with an academic center. Fifty-one interviews of rural physicians, nurses, physician assistants, and nurse practitioners showed both a need and desire for access to information resources [17].

Goals and hypothesis

This study sought to determine which rural health care providers found more useful in answering everyday clinical questions: electronic PoC DynaMed, which is more clinically oriented, or electronic PoC AccessMedicine, which consists primarily of a health sciences textbook collection. We hypothesized that free access to the explicitly clinical format of the PoC resource DynaMed would result in more extensive use than a baseline of zero over a six-month period than the electronic PoC textbook collection AccessMedicine. We felt this would be due to greater utility of DynaMed in clinical practice. We also predicted that clinicians using the clinically oriented PoC would express higher levels of satisfaction than those using the textbook-based PoC and that clinicians using these PoC resources would prefer using them over other information resources.     

The Health Information Literacy Research Project

Objectives:

This research studied hospital administrators'' and hospital-based health care providers'' (collectively, the target group) perceived value of consumer health information resources and of librarians'' roles in promoting health information literacy in their institutions.

Methods:

A web-based needs survey was developed and administered to hospital administrators and health care providers. Multiple health information literacy curricula were developed. One was pilot-tested by nine hospital libraries in the United States and Canada. Quantitative and qualitative methods were used to evaluate the curriculum and its impact on the target group.

Results:

A majority of survey respondents believed that providing consumer health information resources was critically important to fulfilling their institutions'' missions and that their hospitals could improve health information literacy by increasing awareness of its impact on patient care and by training staff to become more knowledgeable about health literacy barriers. The study showed that a librarian-taught health information literacy curriculum did raise awareness about the issue among the target group and increased both the use of National Library of Medicine consumer health resources and referrals to librarians for health information literacy support.

Conclusions:

It is hoped that many hospital administrators and health care providers will take the health information literacy curricula and recognize that librarians can educate about the topic and that providers will use related consumer health services and resources.

Highlights

• Health care providers responded positively to a health information literacy curriculum offered by librarians and to related resources and services, namely MedlinePlus and the information referral system known as Information Rx.
• Participation in a curriculum increased health care providers'' knowledge of health information literacy, awareness of available consumer health information, and referral of patients to the library for additional assistance.
• Librarian involvement in health information literacy increased the profession''s visibility and perceived value.

Implications

• Consumer health information services and resources offered by librarians can improve the health information literacy skills of health care providers and their patients.
• Training by librarians can increase knowledge of the importance of health information literacy and usage of MedlinePlus and Information Rxs.
• Hospital-based administrators and health care providers can be champions in support of health information literacy and consumer health information services offered by libraries.

     

Putting the pieces together: endometriosis blogs,cognitive authority,and collaborative information behavior

Objective:

A discourse analysis was conducted of peer-written blogs about the chronic illness endometriosis to understand how bloggers present information sources and make cases for and against the authority of those sources.

Methods:

Eleven blogs that were authored by endometriosis patients and focused exclusively or primarily on the authors'' experiences with endometriosis were selected. After selecting segments in which the bloggers invoked forms of knowledge and sources of evidence, the text was discursively analyzed to reveal how bloggers establish and dispute the authority of the sources they invoke.

Results:

When discussing and refuting authority, the bloggers invoked many sources of evidence, including experiential, peer-provided, biomedical, and intuitive ones. Additionally, they made and disputed claims of cognitive authority via two interpretive repertoires: a concern about the role and interests of the pharmaceutical industry and an understanding of endometriosis as extremely idiosyncratic. Affective authority of information sources was also identified, which presented as social context, situational similarity, or aesthetic or spiritual factors.

Conclusions:

Endometriosis patients may find informational value in blogs, especially for affective support and epistemic experience. Traditional notions of authority might need to be revised for the online environment. Guidelines for evaluating the authority of consumer health information, informed by established readers'' advisory practices, are suggested.

Highlights

• Endometriosis patients who blog about the illness may determine authority of information sources through both cognitive and affective methods.

Implications

• Because patients with chronic illnesses might have different authority criteria than medical librarians do, it could be useful to carefully incorporate electronic patient discussion forums, medical blogs written by laypeople, and other nontraditionally authoritative resources into consumer health information selection policies. Standard biomedical resources are certainly important to recommend to consumers, but they do not convey the complete picture of a chronic illness and its related experience.
• Patients with chronic illnesses and caregivers can benefit from sources such as blogs and online discussion lists that provide social and emotional support as well as accounts of “lived experience.”
• An understanding of the patient''s potential epistemological community can make the librarian''s recommendations more appropriate for the individual user.

     

Information-seeking behavior and the use of online resources: a snapshot of current health sciences faculty

Objective:

The research assesses the information-seeking behaviors of health sciences faculty, including their use of online databases, journals, and social media.

Methodology:

A survey was designed and distributed via email to 754 health sciences faculty at a large urban research university with 6 health sciences colleges.

Results:

Twenty-six percent (198) of faculty responded. MEDLINE was the primary database utilized, with 78.5% respondents indicating they use the database at least once a week. Compared to MEDLINE, Google was utilized more often on a daily basis. Other databases showed much lower usage.

Conclusions:

Low use of online databases other than MEDLINE, link-out tools to online journals, and online social media and collaboration tools demonstrates a need for meaningful promotion of online resources and informatics literacy instruction for faculty.

Implications:

Library resources are plentiful and perhaps somewhat overwhelming. Librarians need to help faculty discover and utilize the resources and tools that libraries have to offer.     

Mobile devices in medicine: a survey of how medical students,residents, and faculty use smartphones and other mobile devices to find information

Objectives:

The research investigated the extent to which students, residents, and faculty members in Canadian medical faculties use mobile devices, such as smartphones (e.g., iPhone, Android, Blackberry) and tablet computers (e.g., iPad), to answer clinical questions and find medical information. The results of this study will inform how health libraries can effectively support mobile technology and collections.

Methods:

An electronic survey was distributed by medical librarians at four Canadian universities to medical students, residents, and faculty members via departmental email discussion lists, personal contacts, and relevant websites. It investigated the types of information sought, facilitators to mobile device use in medical information seeking, barriers to access, support needs, familiarity with institutionally licensed resources, and most frequently used resources.

Results:

The survey of 1,210 respondents indicated widespread use of smartphones and tablets in clinical settings in 4 Canadian universities. Third- and fourth-year undergraduate students (i.e., those in their clinical clerkships) and medical residents, compared to other graduate students and faculty, used their mobile devices more often, used them for a broader range of activities, and purchased more resources for their devices.

Conclusions:

Technological and intellectual barriers do not seem to prevent medical trainees and faculty from regularly using mobile devices for their medical information searches; however, barriers to access and lack of awareness might keep them from using reliable, library-licensed resources.

Implications:

Libraries should focus on providing access to a smaller number of highly used mobile resources instead of a huge collection until library-licensed mobile resources have streamlined authentication processes.     

Developing health information literacy: a needs analysis from the perspective of preprofessional health students

Objective:

The research identified the skills, if any, that health preprofessional students wished to develop after receiving feedback on skill gaps as well as any strategies they intended to use to address these gaps.

Methods:

A qualitative approach was used to elicit students'' reflections on building health information literacy skills. First, the students took the Research Readiness Self-Assessment instrument, which measured their health information literacy, and then they received individually tailored feedback about their scores and skill gaps. Second, students completed a post-assessment survey asking how they intended to close identified gaps in their skills on these. Three trained coders analyzed qualitative comments by 181 students and grouped them into themes relating to “what skills to improve” and “how to improve them.”

Results:

Students intended to develop library skills (64% of respondents), Internet skills (63%), and information evaluation skills (63%). Most students reported that they would use library staff members'' assistance (55%), but even more respondents (82%) planned to learn the skills by practicing on their own. Getting help from librarians was a much more popular learning strategy than getting assistance from peers (20%) or professors (17%).

Conclusions:

The study highlighted the importance of providing health preprofessional students with resources to improve skills on their own, remote access to library staff members, and instruction on the complexity of building health literacy skills, while also building relationships among students, librarians, and faculty.

Highlights

• After receiving feedback on skill gaps, most preprofessional health students intend to develop their information literacy skills.
• Some students report that a trip to the library is a barrier to using library resources.
• Students see the need to build their information evaluation skills, knowledge of citations and plagiarism, and library skills, which they differentiate from Internet skills.
• Students are more likely to identify librarians as sources for assistance in finding information than faculty or peers after receiving individual feedback explaining the role of libraries and library staff members.

Implications

• Students'' health information competencies can be built through assessment and feedback that reveals skill gaps, highlights misconceptions, and offers ideas on how to improve.
• Access to professionally designed self-study resources is needed for students who intend to develop health information competencies on their own.

     

Case study: the Health SmartLibrary experiences in web personalization and customization at the Galter Health Sciences Library,Northwestern University

Question:

How can the user''s access to health information, especially full-text articles, be improved? The solution is building and evaluating the Health SmartLibrary (HSL).

Setting:

The setting is the Galter Health Sciences Library, Feinberg School of Medicine, Northwestern University.

Method:

The HSL was built on web-based personalization and customization tools: My E-Resources, Stay Current, Quick Search, and File Cabinet. Personalization and customization data were tracked to show user activity with these value-added, online services.

Main Results:

Registration data indicated that users were receptive to personalized resource selection and that the automated application of specialty-based, personalized HSLs was more frequently adopted than manual customization by users. Those who did customize customized My E-Resources and Stay Current more often than Quick Search and File Cabinet. Most of those who customized did so only once.

Conclusion:

Users did not always take advantage of the services designed to aid their library research experiences. When personalization is available at registration, users readily accepted it. Customization tools were used less frequently; however, more research is needed to determine why this was the case.     

��Information Survival Skills��: a medical school elective

Objective:

The authors developed an elective course to assist students in (1) understanding the changing nature of scholarly communication and online publishing, (2) identifying resources and strategies for searching current best evidence, and (3) demonstrating effective communication of information.

Setting:

The course took place in a medical school in the Southwest.

Participants:

Second- and third-year medical students participated in the course.

Intervention:

A pass-fail, undergraduate-level elective was first offered October to December 2006. This 7.5 hour course, developed and co-taught by 2 health sciences library faculty, consisted of hands-on exercises, small group discussion, and didactic lecture.

Conclusion:

Presenting a medical school elective is one possible outlet for intensive bibliographic instruction. Illustrating the flow of information from creation to management and presentation affords students an opportunity to understand information in context. This elective has been consistently ranked very high in student evaluations and led to new and expanded teaching opportunities.     

The impact of library instruction: do first-year medical students use library resources specifically highlighted during instructional sessions?

Objectives:

The research sought to determine if first-year medical students consulted and cited resources specifically highlighted during library instructional sessions.

Methods:

Students attended a library resources instructional session. Resources that pertained to the students'' assignment were demonstrated and discussed. The students created a report including citations from relevant literature. The citations were analyzed and categorized as: a resource discussed at the instructional session, a resource found on the course LibGuide, a library resource, course material, or some other resource. All citations were subcategorized as print or electronic.

Results:

Three years (2008–2011) of data analyzing 2,983 citations showed that 49.55% of all citations were from resources discussed during library instructional sessions; 21.86% came from resources with links on the course LibGuide; 77.51% were from library resources; and 90.68% came from electronic resources.

Conclusion:

Students cited resources specifically highlighted during library instructional sessions for their assignments. The percentage of all citations coming from resources highlighted during the instructional sessions or found on the course LibGuide indicates that library instruction had an impact on the students'' work.

Highlights

• Review of the literature shows that instruction about library resources accompanied by clear guidelines on scholarly research methods and resources provided by course instructors have the biggest impact on the quality of cited materials in student bibliographies.
• Graduate medical students cited library resources more frequently than nonlibrary resources for their assigned coursework.
• Graduate medical students cited materials and resources specifically highlighted during library instructional sessions for their assigned coursework.

Implications

• Instruction about library resources tailored to medical students'' assignments impacts the resources that the students consult and cite for their assignments.
• Using the information gathered from citation analysis to modify teaching plans can impact the effectiveness of library instructional sessions.

     

Finding alternatives when a major database is gone

Question

What to do when a major database ceases publication?

Setting

An urban, academic health sciences library with four campuses serves a university health sciences system, a college of medicine, and five other health sciences colleges.

Methods

Usage statistics of each e-book title in the resource were carefully analyzed. Purchase decisions were made based on the assessment of usage.

Results

Sustainable resources were acquired from other vendors, with perpetual access for library users.

Conclusion

This systematic process of finding alternative resources is an example of librarians'' persistence in acquiring perpetual electronic resources when a major resource is cancelled.     

Beyond citation analysis: a model for assessment of research impact

Question:

Is there a means of assessing research impact beyond citation analysis?

Setting:

The case study took place at the Washington University School of Medicine Becker Medical Library.

Method:

This case study analyzed the research study process to identify indicators beyond citation count that demonstrate research impact.

Main Results:

The authors discovered a number of indicators that can be documented for assessment of research impact, as well as resources to locate evidence of impact. As a result of the project, the authors developed a model for assessment of research impact, the Becker Medical Library Model for Assessment of Research.

Conclusion:

Assessment of research impact using traditional citation analysis alone is not a sufficient tool for assessing the impact of research findings, and it is not predictive of subsequent clinical applications resulting in meaningful health outcomes. The Becker Model can be used by both researchers and librarians to document research impact to supplement citation analysis.     

Electronic resources preferred by pediatric hospitalists for clinical care

Objectives

There is little research on pediatric hospitalists'' use of evidence-based resources. The aim of this study was to determine the electronic resources that pediatric hospitalists prefer.

Methods

Using a web-based survey, the authors determined hospitalists'' preferred electronic resources, as well as their attitudes toward lifelong learning, practice, and experience characteristics.

Results

One hundred sixteen hospitalists completed the survey. The most preferred resource for general information, patient handouts, and treatment was UpToDate. Online search engines were ranked second for general information and patient handouts.

Conclusions

Pediatric hospitalists tend to utilize less rigorous electronic resources such as UpToDate and Google. These results can set a platform for discussing the quality of resources that pediatric hospitalists use.