Barriers and Enhancersto the EBM process

12th June, 2007

Jane McHugh, Information SpecialistDr Klara Brunnhuber, Clinical Editor

BMJ Publishing Group Ltd.

Agenda

• EBM process: From unrecognised information need to evidence-based practice

• Enhancers and barriers to EBM process

• Role of clinical librarian services within EBM process

Methods

• In-depth data analysis of the papers identified by M. Dawes’ systematic review*

• Recording barriers and enhancers to the EBM process

• Grouping barriers / enhancers by SPECK concepts

• Mapping clinical librarian services to the EBM process

*Dawes M. Sampson U. (2003) Knowledge management in clinical practice: a systematic review of information seeking behaviour in physicians. Int J Med Inform. 71: 9-15.

EBM Process

Results based on Dawes’s review: Number of studies included

0

2468

10

12141618

Step 0 to 1 Step 1 to 2 Step 2 to 3 Step 3 to 4 Step 4 to 5

Total

Enhancers

Enhancers*

Barriers

Barriers*

Quantitative analysis in review

SPECK concepts

Enhancers and barriers to the EBM process

EBM Step

Concepts influencing the EBM process

S(Setting)

P(Patient/problem)

E(External input)

C(Clinician)

K(Knowledge resource)

Unidentified information need

2

8

E + B E E/E* B

Recognised information need

14

6

B

Reported clinical question

7

17

B E+B E/E* E + B/B* E/E* + B/B*

Search 19

9

E + B B/B* E + B

Evidence-based answer 11

4

E E + B E + B

Evidence-based practice 5

No. of

stu

die

s

E: Enhancer; B: Barrier; *: Perceived enhancer/barrierBased on Dawes’s review (2003)

Step 0:

Step 1:

POSSIBLE BARRIERS

•S: Working in isolation•C: Existing thinking patterns•C: Loosing face in front of juniors•C: Lack of time

POSSIBLE ENHANCERS

•S: Exposure to questions/ problems (from seniors, colleagues, training, exams)•E: Journal subscription

RESULTS

Step 1:

Step 2:

POSSIBLE BARRIERS

• C: Forgetfulness • C: Lack of time • C: Lack of skill to formulate questions

POSSIBLE ENHANCERS

RESULTS

Step 2:

POSSIBLE BARRIERS

Step 3:

•S: Dealing with many specialty areas•S: Lack of access to resources•S: Lack of time due to urgency of decision•S: Messy office•P: Question too general•P: Lack of urgency•C: Lack of time•C: Lack of search skills•C: Lack of knowledge about resources•C: Forgetfulness•C: Belief that resource won’t deliver answer•C: Belief that answer won’t change patient management•C: Belief that no answer exists•C: Perceived effort•C: Hesitation to contact colleagues•C: Lack of interest•C: Lack of energy due to long working hours•C: Lack of computer literacy•K: Huge volume of literature•K: Cost of resources

POSSIBLE ENHANCERS

•P: Urgency of need•E: Search skill training•C: Belief that answer exists•C: Belief that patient will be harmed without answer•C: Belief that patient expects answer•C: Belief that patient expects doctor to know answer•C: Fear of malpractice liability•C: Recently trained, with academic appointment, involved in research, member of journal club •K: Access to full text articles*•K: Easy, fast access to reliable, trustworthy, familiar, convenient, searchable extensive/complete resource/service•K: Ideal resource*: Immediate, easily accessible, concise, organised, high- quality information, answering specific questions, usable in patient’s presence, more than just a list of references

also covered by Dawes’s review

Step 4:

POSSIBLE BARRIERS

•E: Slow/inconvenient IT systems•C: Lack of appraisal skills•C: Lack of time•C: Time available*: 10-30min for research questions; less for clinical questions•C: Difficulty finding relevant material•K: Resource out of date/of low quality•K: Lack of access to good images•K: Technical language of material•K: Inadequate indexing of material•K: Answer not concise enough to address point-of-care questions•K: Answer delayed

Step 3:

POSSIBLE ENHANCERS

•E: Info on resources from colleagues/training•E: Critical appraisal training•K: High quality, credible, easily understandable resource, providing all necessary detail

Step 4:

Step 5:

POSSIBLE BARRIERS

•S: Inadequate local resources•C: Existing working/thinking patterns and habits

POSSIBLE ENHANCERS

•E: Answer confirmed by additional literature search•E: Opportunity to discuss answer with colleagues/ someone who has applied it/at journal club•C: Reported results compare well with experience•K: Peer-reviewed article

Current clinical librarian services•Encouraging questioning/learning culture and a greater willingness to check out the evidence as part of everyday patient care

•Involvement in journal clubs, delivering EBM skills

•Current awareness services / bulletins

•Attending ward rounds/clinical meetings

•Training how to formulate questions

•Question Answering Services

•Training how to search

•Question Answering Services

•Collating and grading results against evidence hierarchy

•Setting up databases of answered clinical questions

•Training how to appraise articles

•Requesting feed back on provided services

•Following up on service’s impact on clinical care

Next steps

• Update of Dawes’ SR (special focus on electronic knowledge resources)

• Additional search covering the last EBM step (putting EBM into clinical practice)

Thank you

• Jane McHugh

jmchugh@bmjgroup.com

• Klara Brunnhuber

kbrunnhuber@bmjgroup.com