Bringing information to doctors
With public-sector cuts widespread and the costs of providing healthcare going up, information for health professionals is being increasingly squeezed. Sian Harris reports on challenges facing medical librarians and clinicians and some of the tools that are emerging to help make sense of the mass of health information available
‘Journals aren’t interchangeable like pills and pillars,’ stated Anne Murphy at the UKSG meeting held in April this year. She and colleagues at Adelaide & Meath Hospital Library, Dublin have been struggling to argue this case in the face of drastic cuts to their hospital’s library budget – a 25 per cent cut in 2011 (compared to a hospital average of seven per cent), followed by a further 15 per cent cut in 2012.
Such large cuts necessitated painful decisions about subscriptions, especially as library staff numbers had already been drastically cut. Murphy described how her library consulted with users to decide what to keep and what must go, noting that cancellations risk damaging relations between users and libraries. The library surveyed 500 senior clinical and management staff. ‘We needed evidence and to capture what doctors are using. We wanted to retain the most relevant, best value and most used journals,’ she said.
The initial target was to cancel one journal per department. The library first identified journals that needed to be kept. The team also looked at journal usage and price, with all titles that cost greater than €2,000 or had fewer than 10 downloads up for scrutiny. Librarian knowledge was also necessary in determining the last few journals to reach the cancellation target. ‘We have a disinterested overview of the whole collection that no department could have,’ explained Murphy.
In total, 73 journals were identified for cancellation at the hospital in 2011 (213 journal subscriptions in 2011, compared with 286 in 2010 and 300 in 2009). In 2012 the number of journal subscriptions had to be reduced again to 182.
‘We put the project report on the internet with the list of cancelled journals very clear for users to see,’ said Murphy. ‘It gave the message to users: use the journals or they risk being cancelled.’
She believes that medical staff need to play a more active role in protecting their resources: ‘It’s time for our users to arm themselves to fight for the information they need,’ she argued, adding that ‘publishers have a role to play and I’d welcome collaboration’.
New resources
With so much financial pressure on healthcare, such a scenario is unlikely to be unique to Adelaide & Meath Hospital Library. What’s more, the picture of information subscriptions is also likely to be complicated by the emergence of a range of new types of tools to help medical workflows.
As Rubin Minhas, clinical director of the BMJ Evidence Centre, noted: ‘There has been a big expansion of scientific information and much more is produced than doctors have time to read and evaluate. Information at the point of care is necessary and they need to find that information within about 15 seconds or they give up looking.’
The rationale behind new tools comes from the types of working practices that medical staff have and the ways that information fits into this. There are three distinct ways that doctors work – practice, research and teaching – and each of these comes with different information requirements.
‘Most clinicians are accessing content digitally online but using fixed connections,’ continued Minhas, who explained that doctors use information and tools from publishers such as the BMJ Group to help identify likely diagnoses and plausible tests to be done.
BMJ Group has recently begun to partner with Isabel Healthcare, a company that has developed a diagnostic algorithm that mines content and suggests possible diagnoses for doctors to investigate. The partnership links these possible diagnoses with BMJ’s in-depth resources on conditions.
Integration with electronic patient records is another trend. Evidence Centre is designed to integrate with electronic patient records, with appropriate metadata and tagging, according to Minhas. However, there can be limitations with this on the hospital side: ‘[Development of products to meet user needs] is contingent on the IT infrastructure in the hospital. IT infrastructure is critical,’ he said. He noted that some hospitals and countries are behind others in integrating content with electronic patient records and that this can limit the potential applications.
Making connections
Elsevier has also been working to meet the needs of doctors. User needs played a big role when the company reinvented its MDConsult database into a new and much-expanded resource known as ClinicalKey.
‘Users said they wanted it to be comprehensive, information needs to be from trusted sources and they need a good speed of answers,’ noted Sebastian Vos, senior VP of e-solutions, Europe, Middle East, Africa and Latin America at Elsevier. ‘They didn’t want "good enough". And clinicians don’t want big chunks of information; they just want the answer.’
Sebastian Vos
To develop the tool, the company meshed its taxonomy with all the publisher’s relevant content to, for example, link a disease with suitable drugs and treatments. ‘We’re making connections between content,’ said Vos.
According to Vos, ClinicalKey can be used in diagnosis and keeping up-to-date with current practice. It can also be for information sharing and training. ‘It’s about making doctors’ lives easier. Sharing with colleagues is a big part of their job,’ he said.
In addition, the company is developing the tool to be used by medical students, who may require larger chunks of information, including the underlying science.
Mobile access is also an emerging trend, both on the ward and in the classroom (see box). Many companies are planning or have launched apps and mobile versions of their medical resources.
‘We are planning a release over the summer months to make ClinicalKey tablet-friendly,’ said Vos of Elsevier. ‘It needs to be online because the underlying database is so big – we don’t want to clog up the user’s mobile device – but we are looking into a content-clipping service so that users could look at content as they commute to work, for example.’
Beyond e-books
Oxford University Press (OUP)’s medical handbooks have also evolved over the years to meet new needs of doctors in a digital age.
The Oxford Medicine Online platform, which launched 2009, now has more than 250 titles in it. ‘It is not just about e-books. Instead, it is dynamic, with more online-only content such as images and videos,’ commented Catherine Barnes, editorial director, Medicine Books, Global Academic Publishing at OUP.
Catherine Barnes
‘One of the biggest challenges is how to keep content current,’ she continued. ‘Reference books have very long cycle times so by the time one is published it’s almost out of date. With our Oxford Textbook of Medicine the online entity updates every six months. The aim is to keep it fresh. Users can walk back through versions so it also helps keep the academic paper trail.’
Geography and language
Developing tools for doctors is not straightforward because there are significant geographical differences and these vary depending on speciality and use case.
‘Some specialties travel really well, but some are really hard because of drug information,’ said Barnes of OUP. She noted that producing the Oxford American Handbooks in Medicine required extensive research, with some specialties just requiring a change of spelling and some needing extensive rewriting.
One big issue in medicine is the way that different countries have different guidelines and have approved different drugs for use. According to Vos of Elsevier, ‘in the USA a common treatment for insomnia is Ambien, but this drug is not prescribable in the UK so it should not come up as a potential treatment for this condition in a search by a UK doctor’.
Similarly, Minhas of BMJ noted that strains of tuberculosis are different in India from those in sub-Saharan Africa and so the recommended treatment also needs to be different.
There are also issues about culture and dialect, which affect, for example, the questions used in evaluating mental health, and the people and settings chosen for patient-education and student videos.
Related to geographical differences is the issue of language. ‘We offer navigation in different languages and are looking at translating our whole content for some cases,’ said Minhas. He noted that there is particular interest in translating BMJ content into Portuguese and Chinese.
Vos has similar experiences. ‘We are working on other major languages where they have a strong history of independence in terms of localised content,’ he said, noting that these countries include France, Germany, Spain and Brazil. In addition, he noted, some countries have fewer issues of localised content but users may be happier searching for content in their own language.
Partnerships
Such variations by geography, specialty and how information is used require publishers to work with the users – the doctors. ‘We need informaticists for taxonomies and we need medical expertise. We can’t employ all these people and it is better to develop products with hospital partners and medical partners,’ said Vos.
For many years, there has been talk of medical professionals using mobile devices to access information. While this seems yet to become a strong behaviour pattern for doctors on the ward, there is plenty of experimentation in this area with the health professionals of the future.
- A team at Brighton and Sussex Medical School (BSMS), UK has been investigating and supporting the use of mobile devices for medical students to access textbooks and other resources for several years, in a project known as MoMEd. In 2005 BSMS became the first medical school in the UK to provide PDA devices to students.
As Jil Fairclough, BSMS librarian, observed at the UKSG meeting: ‘There were predictions that PDAs would be as common as stethoscopes but we are not there yet.’
Feedback from use of PDAs has been mixed, as Fairclough and BSMS learning technologist Tim Vincent reported at the UKSG meeting. Students like the quick reference information and said that repetition helped them remember things. They also liked being able to use their ‘downtime’ to look up information. However, they also noted that using mobile devices requires a change in culture and behaviour; students need to have their device with them.
Of course, there is another issue too: since 2005 when BSMS first handed out PDA devices, the iPhone and other smartphones have launched and, in that short space of time, made the PDA virtually obsolete. The evolution of the MoMEd project, which was trialled from November 2011 to February 2012, involves students’ own smartphones and an app developed by the library and learning technologists at BSMS.
‘I doubt we’ll get 100 per cent penetration of smartphones in students,’ noted Fairclough. ‘Some don’t want to learn in that way.’
- Researchers in the Faculty of Health at Birmingham City University, UK have recently begun work on a mobile app to help with training for nurses, paramedics and others.
A lot of students said they were not confident in taking their knowledge into practice,’ said Salim Khan, who is one of the team involved in the project.
‘There are very few apps for health sector,’ he said. ‘When you strip away the veneer and look at content, they are mainly textbooks and our users said they don’t want that.’
The goal of the team is to develop an app that incorporates video, images, tests and animations, to enable students to consolidate and test their knowledge.
‘We want to make the result freely available to all healthcare students. The app we are developing is going to focus on one physiological system – the respiratory system – as a pilot,’ said Khan. ‘If this proves successful we can adapt the design strategy to incorporate all physiological systems.’
