On Thursday morning, after the official conference run, I went to a technology parallel session. One speaker failed to show up, so we heard Michelle Kirkwood on Value of accessing Evidence Based Clinical Reference Content from within the Clinical Workflow. Michelle works for Greater Glasgow and Clyde, the largest health board in Scotland, possibly in the whole of Britain, in the eHealth directorate. Drawing our attention to the Clinical Decision Support (CDS) Roadmap for NHS Scotland and an excellent page of resources prepared by the US Agency for Healthcare Research and Quality In April 2016 they launched Trakcare, a patient information system with embedded evidence: an evidence icon links out to an external page maintained by NHS Education Scotland, taking them on to evidence resources, with no further login required. It links to local resources, for examples pathways, and a clinical portal brings together records from multiple systems. There are three sets of resources: national subscription services, national (i.e. Scotland) in-house services, and local services. National subscriptions include Dynamed (declaration of interest, they paid for Michelle's attendance at the conference). national (Scotland) resources such as SIGN guidelines, and local resources, for example the Adult Therapeutic Handbook. The library and knowledge service offers search services. It too them twenty-four months to develop a guidelines app, a lesson to those of us who think an app can be put together quickly. To overcome the problem of a large staff turnover, they had to do a lot of awareness-raising, putting it in clinical governance bulletins, on the web and Twitter and running pop-up events as well, of course, as new doctor inductions. Among the lessons learnt were the need to have a consistent approach to use of own devices on network and to provide more content for non-medical staff. Next steps include making it –look the same across all health boards, and implementing in other systems (there are 754 in use!). They want to embed their clinical search and synthesis service bit will need to ration it: it offers a four-hour turn round for searches and is labour intensive. Michelle’s presentation may be seen here: https://librarynetwork.zendesk.com/hc/en-gb/articles/115003714549-What-is-Clinical-Decision-Support
The problem with IPs; How to Manage the IP Ranges Publishers Hold to Authenticate Your Library, presented by Ian Hames of PSI , a fascinating presentation, though ta little outside my area of professional practice — they don’t trust me to have anything to do with authentication these days.
The origins of PSI’s solution lie in subscription fraud problems, for example the abuse of personal subscriptions by institutions to defraud publishers, where a personal subscriber might share their access with others in the insitutition. PSI helped publishers take down rogue agents and recovered significant sums for publishers. Publishers suspected that fraud was going online, and so PSI started c hecking IP ranges, finding that, while there was little fraud per se, publishers’ housekeeping of IP ranges was poor. Publishers’ records contained many unverified, or outdated, IP ranges.
So they built a database of institutions and their IP ranges. It works on a self-service basis so, libraries can edit the IP ranges associated with their institutions. The service is free to libraries, but publisher pay a subscription. To give us an idea of the scale, Ian mentioned Oxford University,who needed to change IP ranges. This required 400 e-mails, lots of problems, and no one removed the old IP ranges. There are risks to not updating IP data, chiefly that duplicated or overlapping ranges can make nonsense of usage data. The systems tends to amplify dirty data. There’s also a problem of multiple institutions with the same ranges. While we have DOI for content, ORCID for researchers, there’s nothing to unambiguously identify institutions. Their Global IP Access Database will launch soon at Global IP Access Database soon at https://theipregistry.org/
In some interesting questions, someone suggested that this could be used to detect fake publishers, while someone else asked if they had found any evidence of association with SciHub, to which the answer was yes, a lot, e.g. identify theft and massive downloads.
Then we were back for a plenary with Dr Mark Murphy, a GP and lecturer at the Royal College of Surgeons in Ireland (he has a page on the Health Research Board Centre for Primary Care Research too) whose youth and enthusiasm meant that I struggled to keep up with his argument at times.
To cheers and applause, he declared himself a fan of librarians, and took us thro0ugh his library history, using libraries at UCD, Sligo University Hospital, ICGP and the RCSI. What separates doctors from homeopaths, he asked, the answer being evidence. But doctors still don’t implement evidence-based medicine. Quoting Richard Lehman, whose splendid weekly review of the main medical journals is required reading for all, he said we still train doctors to be ignorant. We [i.e. doctors-TR]over-estimate treatment effects and risks, for example NSAIDs and cardiac arrest. It’s hard to explain risk on the radio. We suffer from cognitive bias and variation is widespread. He discussed the competencies and challenges of modern medicine, citing @Aoife Lawton’s review of competencies needed for health librarians Lawton, A. and Burns, J. (2015), A review of competencies needed for health librarians – a comparison of Irish and international practice. Health Info Libr J, 32: 84–94. doi:10.1111/hir.12093
GPs need to practice shared decision making with patients with multi-morbidities. He was not taught the EBM triad at med school, and papers too often ignore the outcomes that are meaningful to patients. We don’t share evidence well, the linguistic deceit of treatment threatens EBM and we rush into binary thinking. We practice too much medicine — care is often ineffective.
Librarians and GPs have in common that we are both on the outside but with important contributions to make. There’s over-diagnosis and over-detection (e.g. prostate-specific antigen tests, incidentalomas), we treat hypertension as a disease, not as a risk-factor. Dr Murphy quoted some of the authors who had formed his thinking: Petr Skrabanek and his Follies and Fallacies in Medicine, James McCormack, Margaret McCartney and Iona Heath.
Corporate demands are prioritised over evidence. In ethics primum non nocere is not the most important thing, but patient autonomy. It’s normal to die, and to want to die at home. Ireland, he told us, is the next most litigious part of the world after Florida. Half his patients see him for free, half pay. It’s the main determinant of people’s health and care is fragmented by the cash nexus.
Research methodology is poorly understood, especially qualitative research which is under-valued. Critical appraisal isn’t happening and education is the poor relation. Our education doesn’t give sufficient emphasis to the real-world situation, e.g. multi-morbidity. Politics creates everything
He quoted Richard Dawkins on the tyranny of the discontinuous mind. Evidence is much abused in politics. Dr Murphy uses Twitter to lobby politicians and journalists. He quoted the example of Trump’s daughter Ivanka and her #nationallibraryweek tweet.
He suggested a slogan, how to take advantage of your medical librarian. We improve patient care and there are huge opportunities for librarians in general practice. He (rightly) criticising that Gaiman quotation (Google can bring you back 100,000 answers. A librarian can bring you back the right one ) for underestimating our contribution
His talk provide a lot of questions, for example from Sue Thomas on how to achieve patient autonomy in the 'mess we’re currently in', - he says through high-quality decision aids in the consultation,. He sees 35 patients a day, and needs something that will work with that workload. Richard Lehman and others are putting NNTs (Numbers Needed to Treat) into formats patients can understand. Another question asked about multi professional education. Dr Murphy thought librarians could co-deliver teaching on methodology, critical appraisal. And Andrew Booth, who asked a question in, I think, every session he attended, asked that if there are heart-sink patients, are there also heart-sink evidence users? Dr Murphy answered that yes, there were, and we needed to steer the debate towards the evidence.
Then there was another parallel session, and I attended one on research and evidence-based library and information practice (EBLIP). The first presentation was from Sarah Lewis and Tracey Pratchett on STEP, a set of freely available generic e-leaning modules, developed as part of Knowledge for Healthcare. It began with a phone call in January 2016. Sarah and Tracey secured funding from Health Education England. They had a distributed project team and a twelve-member steering group, and consulted to determine priorities, encourage use and buy-in. They had 139 responses from staff (13% response) and 173 from healthcare staff. Their top concern was how to develop a search when it retrieves too many results. Healthcare staff are not interested in advanced search techniques, e.g. thesaurus use. Both groups thought broadening a search should be a priority. E-learning needs to be accessible anywhere and interactive. They derived recommendations for structure, design and content from the survey. They had no baseline measurement. A Virtual Reference Group (I’m one of the 42 members) was set up, using Yammer, to advise on learning objectives and content.
STEP has seven modules; each is short, taking around 20 minutes and interactive. Some of the lessons they learnt is that it’s hard to do things on a large scale and at a distance. Some found Yammer clunky, difficult to engage with. It’s hard to write e-learning materials. But the modules will launch this summer and they have shared their learning on the Knowledge for Healthcare blog https://kfh.libraryservices.nhs.uk/category/service-transformation/service-transformation-e-learning-project-step/
Next was Sandra McKeown of Queen’s University, Ontario, Canada, on evaluating the quality of a literature searching service, of great interest to me and my fellow delegates from Brighton and Sussex NHD Library and Knowledge Service, Rachel Playforth and Igor Brbe, as that afternoon we were to present a paper entitled What do users perceive to be the strengths and weaknesses of librarian-mediated and unmediated evidence/knowledge searches?
Sandra’s work has been published: McKeown S, Konrad SL, McTavish J, Boyce E. Evaluation of hospital staff's perceived quality of librarian-mediated literature searching services. J Med Libr Assoc. 2017 Apr;105(2):120-131. doi: 10.5195/jmla.2017.201
She and her fellow authors used a Critical Incident Technique to ask users to identify and talk about one experience. They discussed their survey with their library team and with experts, and the responses improved its design. They tested it to ensure internal consistency, and calculated the sample size needed to provide 95% confidence.
68% had tried their own search. Satisfaction seems to be related to method of request. They found a significant relationship between satisfaction and librarian clarification of question (compare or finding that the one area where search requesters did not consider mediated searches superior was in the understanding of the search question).
They had few patient care requests. People prefer electronic submission, and are generally satisfied with service, but those using a paper form are less satisfied. They wondered if the paper form is not too PICO based, especially if they receive few patient care questions. For future research they want to look more closely at the method of communication. Their results could be subject to recall and response bias. Compare responders with non-responders?
The last paper was about Australian health libraries and how they could help their parent organisations achieve accreditation, the HeLiNS (Health Libraries for the National Standards) Project Australian hospitals have to meet ten national standards, so they surveyed libraries to see what services they offered to support the standards, for example in governance by managing guidelines documentation, and creating and maintaining repositories of institutional research. Serious safety and quality incidents have provoked an interest in improving resources
In questions, someone asked if Sandra’s research included searches for course work. No, she answered, they exclude them, as indeed we do at Brighton and Sussex NHS Library and Knowledge Service. Andrew Booth (him again)commented on the high methodological quality of the papers and asked how did presenters gain these skills? Two of the speakers had MScs in research or epidemiology, others team had access to an expert. (STEP is not a research project in this sense)All expressed the wish that there was better access to biostatisticians. Another question concerned the Chinese whispers problem of search requests, where the search request reaches the searcher from someone other than the original requester, for example the question goes from consultant to registrar to junior loss in translation?