To the Editor:
In your excellent article "What clinical information do doctors need?", I note that there was little reference to the information needs of surgeons, particularly operative information for surgical trainees.
You pointed out the requirement for something more than current information sources. I may have an answer to the surgical trainee's serious present day need for better information in operative surgery.
I write and produce interactive multimedia operative surgical training programs on CD-ROM. They vastly improve the provision of operative information. Each disk is equivalent to a training course plus the first ten or more cases that a trainee might operate on. They combine high relevance, validity and usefulness, to a degree that has not been achieved before. They entail very low work since they can be used in a trainee's hospital or home without the expense and time involved attending courses. They are recognised by the American Medical Association for 4 hours of Category 1 Continuing Medical Education Credits.
The information consists of much previously unrecorded experience of senior and internationally recognised surgical experts. Each disk amounts to about 30 times the information of an operative surgical textbook. The information is made instantly accessible to the trainee using a new surgical language called Scalpelfax. Each detailed step of Scalpelfax may describe equipment, materials, technique, landmarks, endpoints, checks, problem solving, when to call the boss, etc, plus annotations to keep the text always up to date. The language is suitable for teaching any complex procedure universally.
The multimedia features include text, sound track in UK or US English, diagrams, photographs, animations and videos.
The interactive features are very advanced including quizzes, scoring, surgical decision, practice, operative problem simulations and more recently, trainee aptitude profiling.
Pure computer power is incorporated in drug dosage calculators, customisable co-ordinated care plans and information for patients.
No previous computer skills are needed, since the program will train a beginner within two minutes.
I should be delighted to send you a copy of the laparoscopic cholecystectomy disk for you to try out for yourself
M H Edwards FRCS
Northallerton Health Services
To the Editor:
As a professional medical librarian, I read with interest your article, Information in Practice: What Clinical Information Do Doctors Need? (26 October, 1996). Medical librarians have long understood the problems doctors face in dealing with the questions that arise daily in medical practice. It is perfectly true, as Williamson et al. conclude, that "science information management is a critical professional skill that is not adequately taught in undergraduate medical education." But it is taught in Master's in Library and Information Science (MLIS) graduate programs!
At this hospital, the doctors who are most often sought out as experts by their colleagues are the ones who come into the Library, introduce themselves, and find out what services are available to them. They tell the medical librarian which subject areas are of interest to them, and they take advantage of the Library's table of contents service, current awareness database searches, document delivery service, and more. When a question arises in the treatment of a patient, they telephone the Library and ask for a literature search.
The medical librarian is responsible for these services, and for deciding (with a great deal of input from the Medical Staff) which journal subscriptions to maintain, which books to purchase, and which databases to search. In your description of the characteristics of the ideal "information tool that may transform medicine" your first requirement is that it "must be able to answer highly complex questions and so will have to be connected to a large valid database." Not only am I "connected" online to the databases I use, I have a clear
understanding of how each one is put together, how it is indexed, and how best to retrieve articles on a particular subject.
There also is the human element. The medical librarian gets to know individual patrons, and is able to anticipate their informational needs. Often, I can have a crucially important article in a physician's hands long before he or she would otherwise know of its existence, before it is cited in any database, because I see it first, and I know who will want it. I may not be the computer Negroponte wishes for, but I can "know you, learn about your needs, and understand verbal and non-verbal languages."
I believe that you are correct in assuming that there will evolve a "family of tools" to help the physician gather the information he or she needs, but as far as searching (and sifting through) the medical literature, there is a very good "tool" already available to you. Your medical librarian is here to serve you-stop by and introduce yourself!
Karen W Moody MLS
Sequoia Hospital
To the Editor:
Electronic Medical References are being Used by Practitioners
A frequent conclusion of literature reviews such as yours(1) is that current information systems are not used because they are not based on users' requirements. In fact user need driven electronic medical reference tools are being developed and used.
The evidence for this is more likely to be held by commercial organisations than to be found in publications. Mentor(a), for example, is an immediate use electronic medical reference for primary care team members and junior hospital doctors. EBM(b) and best practice are incorporated in 2200 succinct peer reviewed articles which are regularly, sometimes immediately, updated electronically. Mentor is linked to the patient record, patient information, protocols, Read and a drug database in more than 2100 general practices serving approximately 22% of the UK population.
Subjective comment on the value of each interaction, requests made to the computer and the information viewed can be gathered electronically. New material can be reviewed by users enabling system validation and personal education(2).
Recent analysis of 93,481 Mentor(3) interactions revealed approximately a third of GPs used the system on average once per working day. A quarter of these interactions took place during the consultation. Two thirds of assessment scores indicated resolution of clinical problems or performance enhancement through system use. The figures show real usage and perceived value of a passive information system.
I would question the validity of your generalisation that reference sources are required for every consultation. Irrespective of time constraints, surely the educational content of an interaction should prepare users for dealing with future similar circumstances minimising the need for repeated system use and potentially annoying computer prompting.
Our experience, in developing Mentor, is that some doctors will use familiar text based references and others electronic media if faster and more up to date. Ease of use and robustness of software are also critical determinants of source chosen.
Mentor's development cycle includes continuous investigation of users' needs and resultant refinement of content, software and software interconnection. The scope and speed of change render standardised objective methods of measuring performance inappropriate and might, as we are commercial, account for our inability to attract funded independent assessment with publication of results.
Enormous potential exists for providing clinicians with layered electronic medical references linking immediate use local resources with remote access. Your vision could only be realised in this country by academics, Government, publishers, educators and system suppliers pragmatically collaborating to prevent a further "missed opportunity"(1).
Gordon Brooks MB ChB, PHD
Medical systems designer/developer & EMIS Employee
References
1 Smith R. Information in Practice. BMJ 1996;313:1062-8
2 Westerman C, Brooks G J, Longmore J M. Information overload. BMJ 1993;307;679
3 Brooks G J. Presentation to Annual Primary Health Care Specialists Meeting, Downing College Cambridge, 14 September 1996.
(a) Mentor is a joint development by Egton Medical Information Systems and Oxford University press.
(b) Evidence Based Medicine
To the Editor:
Your article "What clinical information do doctors need?"(1) paints a very challenging scene for clinical information systems. For many years, Wirral Hospital Trust's IT strategy has been to support clinical decision making. Wirral is one of the two national pilot sites for the electronic patient record. Junior doctors use the system on a daily basis, and all pathological and radiological requests are made using the computer as is inpatient prescribing.
Two approaches have been adopted. Firstly we provide information to the clinician when ordering tests. We have adopted many of the Royal College of Radiology guidelines and these have shown to reduce the number of requests. Using the computerised pharmacy system, we have altered prescribing behaviour and achieved stabilisation of the drug budget despite an increase of 14% in FCE activity. We are, with the Wolfson Institute in Birmingham, developing a rules based prescribing system to search the patient's record for specific data and inform the physician on the safety of the prescription.
The second approach is to deliver structured information to the clinician using the Path.Finder system(2). This is a locally developed information system for GP's and Hospital Clinicians. It has been shown to significantly influence both clinical and referral practice It was chosen as the most efficient means of delivering targeted information to the clinician rather than the Internet, as the information can be structured, condensed for rapid assimilation and yet reflect local circumstances. The information is often referenced as evidence or consensus based and has been mostly derived from colleagues on the Wirral who have been most generous in their support. The project is now being developed by 10 other UK Trusts, under the auspices of the British Association of Medical Managers (BAMM). Each Trust will share the Wirral set of information, adapt it to reflect their local circumstances and then report back to the National Library. We have been able to demonstrate that a Read Code can trigger the correct page of Path.Finder to open. The project also provides the opportunity for patient groups to share specific information about relevant services such as leisure and health facilities, disease and drug information, benefit advice and other patient support groups (see table). Further modules are currently under development including multimedia clinician education.
We believe this project will provide a solution to many of the issues raised by this article.
Dr T D Kennedy
Dr S Magennis
Mrs Cathy Harris
Wirral Hospital
References
1 What Clinical Information do doctors need? Richard Smith BMJ 1996;313,1062-8
2 Path.Finder: an interactive clinical information system I.E.Buchan, T.D.Kennedy Int J.Health Care Quality Assurance 1995;8(7),32-35
To the Editor:
I read with great interest Richard Smith's article on Information in Practice in the BMJ (October 26 1996) and look forward to future articles on managing clinical information which will appear regularly in your journal
Unfortunately Richard Smith missed one of the key articles relating to the Rochester study (1). Physicians were asked to request some information related to a current clinical case and then to evaluate its impact on the care of their patients.
As a result of the information provided by the Library 80% physicians said that they probably or definitely handled some aspect of patient care differently than they would have otherwise done. Changes in the following area of care were reported by the physicians: diagnosis (29%) choice of tests (51%) choice of drugs(45%) reduced length Of stay (19%) and advice given to the patient (72%). The physicians also said that the information provided by the Library helped them to avoid the
following: hospital admission (12%) patient mortality (19%) hospital infection (8%) surgery (21%) and additional tests or procedures
(49%)
In general, the physicians rated the information provided by the Library more highly than that provided by other information sources such as diagnostic imaging lab tests and discussions with colleagues.
The Rochester study confirmed earlier studies that information provided by hospital libraries is perceived by physicians as having a significant impact on clinical decision making.
With the advent of evidence based medicine the importance of getting the right piece of information into the hands of the right doctor at the right time, for quality patient care, cannot be over emphasised.
Beatrice M Doran
Royal College of Surgeons in Ireland
Reference
1 Marshall, Joanne The impact of the hospital library on clinical
decision making: the Rochester Study. Bulletin of the Medical Library Association 1992;80(2):169-178.
To the Editor
Richard Smith has broken a fundamental rule by not citing the original authors from whom he drew information.(1) Instead, he quoted from an author(2) who cited the three original papers(3)(4)(5). This suggests that he has not read the original articles. Moreover, it may have misled your readers. In citing this paper from 1995, he implied that this research on costs and time spent on information handling took place in the 90s. In reality, the cited author, Hersh, cited three papers from 1966, 1970 and 1973. I find it hard to believe that nothing has changed in costs as well as time spent on information handling over the last thirty years. In this way, Robert Smith has contributed to his own statement that "some of the information in doctors' heads is out of date and Wrong".
Anita Verhoeven M.D.
University Library
References
1 Smith R. What clinical information do doctors need? BMJ 1996;313:1062-8.
2 Hersch W R, Lunin L F. Perspectives on medical informatics: information technology in health care. Introduction and overview. J Am Soc Inf Sci 1995;46:726-8.
3 Jydstrup R A, Gross M J. Cost of information handling in hospitals. Health Serv Res 1966;1:235-71.
4 Mamlin J J, Baker D H. Combined time-motion and work sampling study in a general medicine clinic. Med Care 1973;11:449-56.
5 Richart R H. Evaluation of a medical data system. Comput Biomed Res 1970;3:415-25.
To the Editor:
What clinical information do doctors need? BMJ 1996; 313: 1062-8
Information needs do arise regularly when doctors see patients
Types of information need and complexity of questions
Information required is more than just medical knowledge
Doctors asking other doctors for information
Answering questions from MEDLINE with electronic sources
Information overload and lack of organisation of information
Christine Urquhart
John Hepworth
Department of information
Reference
1 Urquhart C J and Hepworth J B. The value to clinical decision making of information supplied by NHS library and information services (BLR & DD Report 6205). Boston Spa, W. Yorks LS23 7BQ: British Library Document Supply Centre, 1995.
To the Editor:
Information shared in mentoring must remain confidential
While Robert Alliott makes passing mention of mentoring schemes in several regions in his article in Career Focus,(1) he does not acknowledge the evident and specific influence on his own study of the pioneering three year mentor project in South Thames, which is currently being evaluated. A particularly relevant finding from this evaluation is the link between effective outcomes of mentoring interventions and the mentee's reliance on the confidentiality of information shared with the mentor. Alliott's suggested extended use of such privileged information, even if anonymous, suggests the concurrent pursuit of institutional objectives, which would risk distortion and diminution of the reason for the existence of mentoring support and, on the basis of our experience in South Thames, would be hard to justify.
Mentoring is well established in other professions as a means of professional development,(2) and the literature points to inherent tensions in the role of the mentor If he or she also contributes, at whatever distance, to an assessment of performance at work.(3) Feedback on performance is, of course, essential for professional development,(4) and the mentor is poised to provide it, but only if certain criteria are met.
The evaluation in South Thames shows that the unbiased and neutral role of the mentor, with the crucial absence of any "report back" function, is a critical factor in the mentee's ability to confront problems relating to organisations and clinical management and to work confidently towards achieving positive and effective change. All 65 mentees who were questioned attached appreciable value to the absolute confidentiality of their discussions with their mentor. Indeed, anxieties about how privileged information from the mentor interview might be used led to debates about what link (if any) might develop between, for example, mentoring and recertification.
The Anglia project discussed by Alliott provides further evidence of the potential of mentoring in reducing job related stress. South Thames can go further, with indicators that suggest that organisational issues such as morale and retention of practitioners can thereby also be addressed. Our experience, however, leads us to judge that use of information voiced in individual mentoring sessions to help resolve wider organisational issues, by another institutional route, will critically undermine the foundation on which our model of mentoring for promoting continuing medical education and professional development is essentially based.
The author's suggestion that local medical committees and the General Medical Council could make Constructive use of this source of information puts confidentiality at risk. This must be strictly adhered to if the essential principles of mentoring are to be upheld.
Rosslynne Freeman
South Thames
References
1 Alliott R. Facilitatory mentoring in general practice. BMJ 1996;classified suppl: Sep 28.
2 Merriam S. Mentors and proteges: a critical review of the literature. Adult Education Quarterly 1983;33:161-73.
3 Shaw R. Can mentoring raise achievement in schools? In; Wilkin M, ed. Mentoring in schools. London: Kogan Page, 1983:10-1.
4 O'Hanlon C. The importance of an articulated personal theory of professional development. In: Elliott J, ed. Reconstructing teacher education. London; Falmer, 1993:23-4.
Consultant Surgeon
Friarage Hospital
Northallerton
North Yorkshire DL6 1JG
Tel: 01609 779911
Fax: 01609 777144
Medical Librarian
Health Sciences Library
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(Medical Informatics)
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FRCP on behalf of the Path.Finder Consortium
Consultant Physician and Rheumatologist
Director Clinical Practice Research Unit Wirral Hospital Trust
General Practitioner
Clinical Practice Research Unit Wirral Hospital Trust
Path Finder Co-ordinator
Clinical Practice Research Unit Wirral Hospital Trust
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Librarian
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Research librarian
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Related work in the UK was funded by a group of Postgraduate Medical Deans and the British Library R&D Department(1). A critical incident study of the patterns of information need and use was conducted among a random sample of almost 300 medical staff (hospital and GP) at 11 UK sites. Another survey examined the impact of information obtained on clinical decision making. The following findings are pertinent to some of the conclusions in the review in BMJ 1996; 313:1062-8.
Patient care was involved in 66% of the information seeking incidents, and was the sole purpose in 37%. Personal education or teaching was involved wholly or partly in 48% of the incidents.
The main purposes were concerned with drug or therapy queries (35% of incidents), rare conditions (32%), and personal education (31%). Generally, information needs which prompted an information search were "multi-purpose".
The main impacts of information on clinical decision making were: Recognition of abnormal or normal condition; Identification/evaluation of alternative therapies; Improved quality of life for patient and/or family. The need for information often goes beyond the clinical facts.
Our findings differ from the conclusions of the review, although the preference for easily accessible information still holds. GPs turned to colleagues in one out of four incidents, but used other sources as well.
Dial-Up MEDLINE was often valued as it provided easy access to the medical literature out-of-office hours (and often at home).
Comments in interviews suggested that the difficulty sometimes is not so much coping with the overload but finding information on the practical and organisational aspects of care. Profiles of information need and use varied according to career stage.
Lecturer
Senior Lecturer
and Library Studies
Llandbadarn Fawr
Aberystwyth
Ceredigion SY23 3AS
Wales
UK
Tel: (01970 623111
Fax: (01970) 622 190
E-mail.cju@aber.ac.uk
Mentor project leader
Thames Postgraduate Medical and Dental Education
Surrey Research Park
Guildford GU2 5RF