Variation in the use of online clinical evidence: a qualitative analysis
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.
- 1
What factors explain differences between professional groups’ use of CIAP?
- 2
What factors explain differences between high use and low use hospitals?
- 3
What are the main purposes clinicians report for using CIAP? Do these differ between professional groups or hospitals?
Section snippets
Sample
Three hospitals in the state of NSW were selected as case study sites. One high-use hospital from a rural area (‘high rural’) and one high-use hospital from a metropolitan area (‘high metro’) were chosen to contrast geographical location whilst keeping rates of utilization matched. A low use hospital (‘low rural’) from the same Area Health Service as the high-use rural hospital was also selected. This enabled broad organizational factors to be controlled for when making comparisons between the
Main factors influencing health professionals’ use of CIAP
The major categories of discussion generated from the textual analysis were:
- 1
Reasons for use:
- a
Clinical (use for clinical practice).
- b
Professional development (use for professional development-studying, teaching others).
- a
- 2
Factors influencing use:
- a
EBP (attitudes towards seeking best evidence for clinical practice).
- b
Training and information retrieval skills (amount of training received in using CIAP, confidence in database searching skills, success in finding information required).
- c
Access, speed of PCs
- a
Professional factors
A key finding was that there are marked differences in the way the different professional groups talked about seeking and applying clinical information in their work. Whereas medical staff used CIAP to enhance their knowledge and to improve patient care, nurses and allied health staff were in a state of flux and were grappling with the idea of incorporating up-to-date information into their everyday clinical practice. Nurses showed a desire and need to be better informed, but also a dilemma in
Conclusion
The qualitative design enabled an understanding of contextual issues influencing CIAP use that would not have been uncovered using quantitative methods such as a randomized controlled trial (RCT). The results compliment our quantitative study of web log analysis in helping to understand why uptake of CIAP is considerable in one setting yet poor in another. Many of the factors identified will influence equally the use of other new point-of-care clinical systems. The results support the argument
Acknowledgements
This work was funded by the New South Wales Department of Health. The framework for the CIAP evaluation was initially developed by Jeremy Wyatt, Rohan Jayasuriya and Enrico Coiera. We thank all the staff in the three hospitals who gave their time to take part in the study and those staff who helped organize meetings, interviews and focus groups.
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