Variation in the use of online clinical evidence: a qualitative analysis

Abstract

Objective: To investigate factors influencing variations in clinicians’ use of an online evidence retrieval system. Setting: Public hospitals in New South Wales, Australia. Method: Web log analysis demonstrated considerable variation in rates of evidence use by clinicians at different hospitals. Focus groups and interviews were held with 61 staff from three hospitals, two with high rates of use and one with a low rate of use, to explore variation in evidence use. Results: Differences between hospitals’ and professional groups’ (doctors, nurses and allied health) use of online evidence could be explained by organizational, professional and cultural factors. These included the presence of champions, organizational cultures which supported evidence-based practice (EBP), and database searching skills of individual clinicians. Staff shortages, ease of access and time taken to use the online evidence system were cited as barriers to use at the low use site, but no objective differences in these measures were found between the high and low use sites. Conclusion: Social and cultural factors were found to be better discriminators of high and low evidence use than technical factors.

Introduction

One strategy to encourage evidence-based practice (EBP) among clinicians is the provision of online access to knowledge resources. In 1997, the state Health Department of New South Wales (NSW), Australia, developed the Clinical Information Access Program (CIAP) [1], which provides approximately 55 000 clinicians (doctors, nurses and allied health staff) with access to a wide range of bibliographic and other clinical information resources (Table 1) at the point-of-clinical care [2]. Staff access the website using an organizational password. Staff can also use the password to access the website from other places such as home.

A web log analysis of CIAP use demonstrated considerable variation in the rates of use for individual hospitals across the state and also differences in rates of use by professional groups (see Fig. 1) [3]. The study provided the first population-based data regarding clinicians’ use of evidence but left questions regarding why such variation in rates of evidence use exists.

Online clinical databases have been shown to contain the answers to clinicians’ questions [4], and physicians report the benefits of using resources such as MEDLINE [5], [6], [7]. However, past studies have shown low rates of actual use by clinicians [8], [9], [10]. Physicians appear more likely than other clinical groups to utilize online bibliographic resources [11]. Very little is known about the use of online evidence by nurses or other health professionals.

Previous studies investigating barriers to the use of online resources have identified a range of factors including insufficient training, both in database searching and general IT skills [12], [13], [14], [15], problems with access to computers [16], and excessive amounts of information retrieved [12]. Organizational and social factors such as communication channels that promote discussion within the organization and the existence of ‘champions’ (people who enthusiastically support an innovation) have also been shown to be important predictors of online literature searching [17], [18] and the use of point-of-care clinical information systems [19], [20]. Reasons for professional differences in online evidence use, or the role of organizational factors in influencing its use have received little attention by researchers. In summary, the existing research literature only goes some way to suggesting possible reasons for variation in use of online knowledge resources. Organizational, social and professional factors have been hypothesized to be at least as important as technical and practical factors [17], [19], [20].

We undertook a study to investigate whether such factors differentiate high and low use CIAP hospitals and/or explain differences in evidence use by professional groups. The approach taken was to talk with professionals at both high and low use CIAP hospitals to gain an understanding of how they saw CIAP use in the context of their clinical work and to identify specific factors which are enablers or barriers to CIAP use.

The study sought specifically to investigate the following questions.

• What factors explain differences between professional groups’ use of CIAP?

• What factors explain differences between high use and low use hospitals?

• What are the main purposes clinicians report for using CIAP? Do these differ between professional groups or hospitals?