Issues in Clinical Information Delivery

ALTHOUGHTHE PROFESSIONAL LITERATURE CONTINUES to be a major source of continuing education for health care providers, and although libraries are often excellent sources of information that can benefit patient care, the problems in information delivery to clinicians have not yet been solved. The ever-increasing amount of information available and the time and effort required to obtain the appropriate piece of it when required both act as barriers to information use by busy clinicians. The following librar y-related services are discussed as important contributors to clinical information delivery; clinical librarianship; LATCH (Literature Attached to the Chart); end-user searching of computerized databases; quality filtering of the literature; and clinical information systems that integrate internally generated patient care information, such as the patient record, with access to library and information services. An important new role for the librarian is emerging in quality improvement programs that use the literature to assist health professionals in prospectively improving patient outcomes. Ongoing research into both information needs in clinical settings and the impact of library services is required as a basis for effectively meeting practitioners’ information needs. INTRODUCTION Clinical information needs are of special importance because they relate directly to the ultimate purpose of the health care systemthe care and treatment of the patient. Clinical information needs Joanne G. Marshall, Faculty of Library and Information Science, 140 St. Gorge Street, University of Toronto, ON, CANADA M5S 1Al LIBRARY TRENDS, Vol. 42, No. 1, Summer 1993, pp. 83-107 8 1993 The Board of Trustees, University of Illinois 84 LIBRARY TRENDWSUMMER 1993 are different from those related to research, education, and administration because clinicians require rapid access to practical knowledge that can be applied to patient care. The purpose of this article is to review past studies of clinicians’ information-seeking behavior as a basis for discussing various library programs and services designed to deliver information to clinicians. Particular attention is paid to the impact of information on clinical decisions and patient care and to developments in end-user searching of health care databases. The growing relationship among expert systems (such as decision support systems), health care data (such as patient records), and data from factual and bibliographic databases is also discussed as a future trend. Although the discussion of clinical information delivery in this article deals with health care providers as opposed to consumers, the ideal clinical information delivery system includes service to both sides in the professional-client relationship. Informed clinicians as well as informed patients and family members are needed if the most effective and appropriate care is to be provided. Valiant efforts are being made by librarians to meet the growing need for consumer health information; however, the funding for library and information services in hospitals and other health care facilities continues to be mainly for services to providers. For a detailed discussion of consumer health information needs and services, the reader is referred to Dahlen’s article in this issue of Library Trends. In preparing this article, the author was reminded of the lack of research on the information-seeking and use patterns of health professionals other than physicians. Over the last two decades, librarians have responded to the trend toward interdisciplinary health care by broadening their collections and services, but this trend is not similarly reflected in the research literature. There are a great many user studies on physicians, some of which take an interdisciplinary approach, and relatively few studies on other health professional groups such as nurses, nutritionists, physiotherapists, and occupational therapists. Wherever possible, studies of these groups have been included in this article. INFORMATION AND SEEKING USEBY HEALTHPROFESSIONALS Within the field of library and information science, studies of information seeking and use by clinicians fall into the category of “user studies.” This broad research category includes studies of what information needs are perceived, what information-seeking channels are used, as well as what information is actually applied to patient care. As might be expected, library science researchers have been MARSHALL/CLINICAL INFORMATION DELIVERY 85 primarily concerned with studies of the use of the library and its resources and services. In the health sciences field, there is a substantial literature dealing with information needs and uses in the context of the education of health professionals-in particular, continuing education needs and preferences. These education-oriented studies provide an opportunity for librarians to view their collections and services as one of a number of formal and informal information sources that clinicians use to meet their information needs. The rapidly changing world of health care knowledge and the problems experienced by clinicians in keeping up to date has led to a third group of studies on methods of disseminating health care knowledge and changing practice behavior to reflect new trends and treatments. The results of these studies are also extremely valuable to librarians. Like the education studies, the practice behavior research allows librarians to examine the information sources used by health professionals as part of the change process. The following review integrates a selection of studies from the three literatures described earlier: (1) library and information science, (2) health professional education, and (3) practice behavior change. Readers who are seeking additional references may wish to consult the reviews prepared by Osiobe (1985) and Elayyan (1988). The studies are presented in chronological order to illustrate the parallel development of relevant research from the three areas. Studies of clinicians’ information-seeking patterns and use have a considerable history. Sherrington (1965) identified 162 studies on the flow of medical information, many of which were sponsored by medical journals or pharmaceutical companies. A recurring theme in several of the early studies (Menzel, 1966; Mayada, 1969; Friedlander, 1973) was that the information use patterns of clinicians differ from those of scientists and researchers. Clinicians had very practical information needs that were of ten best served by informal consultation with colleagues. As a result, clinicians consulted the research literature less frequently. Scientists and researchers, on the other hand, were more extensive users of the literature and libraries because of their need to be aware of new published research findings as a basis for their own work. Mayada (1969) suggested that clinicians required information in different forms and amounts than teachers and researchers. Most clinician literature searches focused on diseases or treatments with drug information being the most frequently requested topic. Textbooks were used most frequently by medical students and residents while medical journals were preferred by staff physicians (Neufeld & Woodsworth, 1972). 86 LIBRARY TRENDWSUMMER 1993 A sociological study in the diffusion of innovation by Coleman, Katz, and Menzel(l966) provides a very detailed view of how physicians adopted a new antibiotic drug. Although physicians became aware of the new drug through the medical literature and from pharmaceutical representatives, this knowledge alone was not usually sufficient to persuade the physician to start prescribing the new drug. Sharing of personal experiences by physician opinion leaders in the community about prescribing the drug turned out to be a key element in the adoption process. This study had a major impact on future diffusion studies which continued to investigate the role of interpersonal networks in adopting innovations (Rogers, 1973). Subsequent research efforts tend to confirm the findings of earlier studies. Strasser’s (1978) study of practicing physicians in New York State found that involvement in research or teaching correlated with greater use of the medical literature and the library. Stinson and Mueller (1980) found that, for a group of 402 randomly selected health professionals, the literature was the most common source of information followed by information from professional colleagues. Health professionals in urban areas made more use of professional colleagues than those in rural or semi-urban areas; clinicians in institutions made more use of colleagues than those in solo or group practice; and physicians in general practice made more use of pharmaceutical representatives than did specialists. Younger clinicians were more likely than older ones to use professional colleagues as information sources. In a study of medical students, residents, and physicians, Northrup et al. (1983) found that the participants relied heavily on their personal libraries because of convenience and the need to obtain the information quickly. A study of physicians in office practice by Cove11 et al. (1985) showed that physicians formulated an average of six questions related to patient management during an observer’s half-day visit or about two questions for every three patients seen. One of the most remarkable findings in the study was that the same physicians had previously reported on a questionnaire that they needed information related to patient care only once a week. Of the questions raised by the physicians during the observation period, only 30 percent of the clinicians’ information needs were met during the patient visit and most often by another physician or health professional. A number of barriers to the effective use of print sources were identified in the study, including out-of-date textbooks in the office, poorly organized journal articles and files, inadequate indexing of books and drug information sources, and lack of time to find the