Jessie McGowan, Doug Salzwedel, Tamara Rader University of Ottawa, Institute of Population Health

1. “Just-in-Time Information” Librarian support at the point of service delivery for Family Health Networks www.justintime-librarian.ca Jessie McGowan, Doug Salzwedel, Tamara Rader University of Ottawa, Institute of Population Health CHLA/ABSC 2006 Vancouver, BC

2. Agenda • Project Overview • Study Protocol • Preliminary Results

3. Project Team Principal Investigators Jessie McGowan, William Hogg Co-Investigator Craig Campbell Librarians Doug Salzwedel, Danielle Worster, Tamara Rader Research Support Jackie Schultz, Enrique Soto, Jennifer Cooney IT Support TrialStat

4. Funding Ontario Primary Health Care Transition Fund

5. The “Just-in-time information” project is designed to test whether or not a librarian consultation service can have a positive impact in Family Health Networks in terms of cost-effectiveness (saving time, workload issues) and improved access to information.

6. Study participants • Physicians, nurse practitioners and allied health staff (i.e., pharmacists) of Family Health Networks (FHNs) or Family Health Groups (FHGs) in the Ottawa area or close rural location. • Second year family medicine residents were also accepted.

7. Study participants • 86 participants (based on BlackBerry costs) • 16 practices were involved in the study

8. Objectives • Does inter-disciplinary collaboration improve access to information for quality patient care decision-making? • Is it cost-effective to use a librarian service to locate and disseminate information to primary care staff in a primary care setting?

9. Will the use of an information, communication technology (ICT) enabled librarian consultation service reduce the workload and/or save time for family physicians, nurses and allied health professionals and office staff in FHNs, whether in urban or rural areas?

10. Secondary Outcomes Measured • Effectiveness of librarian collaboration with physicians, nurses and other allied health professionals. • Improved satisfaction of the workplace environment for providers.

11. JIT Service Description • The service provided answers to reference questions answerable by standard resources in 20 minutes or less) • Service was available from 9-5 M-F • Participants were trained to ask clinical questions using an evidence-based approach (PICO).

12. Project decision processes • A detailed librarian flow chart was developed to assist librarians in selecting electronic evidence-based sources for answering questions. • Evidence-based sources were appraised using an assessment tool from U. Laval. Sources included Clinical Evidence, TRIP (Turning Research Into Practice), CPG Infobase, Cochrane Library…

13. Literature Review • Before, during and after the study we searched the literature for similar studies. • A number of studies were identified and the authors contacted for more information • Research collaboration was established with groups in Montreal, London, ON, and Australia.

15. The JIT Librarian Process Contents: • Question elements: PICO • Types of questions • Special question aspect or modifier • How complex is the question? • Performing a quick and focused search • Appropriate study design • Appraisal • Composing the Answer • Writing in a Neutral way • Process Evaluation • Using the JIT Web Interface

16. Questions are recorded based on level of complexity and type. Complexity: Based on the number of modifiers in the PICO, i.e., a simple question has only one modifier in each PICO element. Type: Therapy, diagnosis, prognosis, prevention, etiology (risk) and “other”.

17. QUESTION: What is the evidence for risks associated with using SSRIs to treat depression during pregnancy? ANSWER: A newly published (April 2006) study in the American Journal of Obstetrics and Gynecology assessed the safety of using SSRIs during Pregnancy. Study design: The authors “carried out a retrospective cohort study of 972 pregnant women who had been given at least 1 (SSRI) in the year before delivery and 3898 pregnant...” Results: “The risks of low birth weigh, preterm birth, fetal death, and seizures were increased in infants who were born to mothers with SSRI therapy…” Conclusion: The use of SSRIs in pregnancy “may increase the risks of low birth weight, preterm birth, fetal death, and seizures…” REFERENCE: Wen SW, Yang Q, Garner P, Fraser W, Olatunbosun O, Nimrod C, Walker M. Selective serotonin reuptake inhibitors and adverse pregnancy outcomes. Am J Obstet Gynecol. 2006 Apr;194(4):961-6. (pdf attached) Thank you for participating in the Just-in-Time project.

18. Qualitative Evaluation • Pre-study evaluation about current information practices • Impact of information retrieval in daily clinical practice* • Service / process evaluation (provide feedback throughout the project period to allow changes to the arrangements to improve service) Pluye P, Grad R. How information retrieval technology may impact on physician practice: an organizational case study in family medicine. Journal of Evaluation in Clinical Practice. 2004 (in press).

19. Pre-study evaluation (Qualitative) Typical demographic information plus: • In the past, if a Just In Time service were available to me, it would have saved me time: • Yes, it would have saved me ____minutes, (per question/day/week?) • There would be no difference in the amount of time spent on the question • No, it would have taken more of my time to use a Just in Time service, approximately _____minutes (per question/day/week?). • If the service would have saved you time, how would you use the saved time? • Spent more time with patient(s) • Saw more patients • Spent time on paperwork, and other non-patient activities • Other: • If you think the service will cost you more time, why? • It will take me longer to formulate the question when I must write it down • The BlackBerry will difficult to use • My questions can’t be answered in 20 minutes and fall out of the scope of the project • Reading and understanding the answer takes extra time • Applying the answer can mean taking more time (for example, ordering additional tests, or collaborating with colleagues).

20. Study Design RCT - Conducted for the last 6 months of the librarian intervention. The object of randomisation is the “answers to questions”. Participants in the study were not randomised.

21. Questions sent to JIT were randomised to be either: Answered (Intervention) or Not answered (Control)

22. Inclusion criteria: Reference questions answerable by standard resources in 20 mins. or less) Example: (Prevention) Should moles be examined or removed to prevent skin cancer in a 28yo man with many moles?

23. Exclusion criteria: Drug Dosage Questions: A 37 kg, 12 yo boy is taking 20mg of dexamphetamine per day for ADHD. Should I change the daily prescription to 30 mg?

24. Exclusion criteria: Complex or Time-Consuming Questions: I’m doing a malaria study and need every qualitative and quantitative study ever done comparing the effectiveness of any treatment, in any population and age group.

25. Participant asks question Request is received by JIT database via email Study Design RANDOMISE Database sequence randomly determines whether the question is control or treatment CONTROL Participant is sent email message stating the question is part of the control TREATMENT Participant receives answer from librarian 24 hours (?) later the participant is sent a questionnaire to see how/if information to answer the question was found The “impact” questionnaire is sent to evaluate answered questions. Assessment of study outcome measures

26. Impact Assessment questionnaire (Qualitative) Select the ONE best answer… High positive impact 1. Practice Improvement: My clinical decision making was enhanced. 2. Learning: I learned something new or updated my knowledge. 3. Recall: I recalled something I had forgotten. Moderate positive impact • Reassurance: I was more confident. • Confirmation: The information confirmed I was doing the right thing.

27. Impact Assessment questionnaire (Qualitative) Select the ONE best answer… No impact • The information had no impact. Negative impact • There was too much information provided. • There was too little information provided. • I disagree with the information. • I think the information is potentially harmful.

28. Answers by Source Type (first answer only)

29. Questions byType

30. Questions by Entry Point (first answer only – approx. 3800 records)

31. Questions by Source (first answer only – approx. 3800 records)

32. Data handling and record keeping • This is being done off-site by an external company. • Project investigators can only access anonymous data.

33. Dissemination Outcomes of the demonstration project will be published in national and international journals Findings will be presented at national and international conferences, as applicable to the audience.

34. Dissemination The concept, procedures and technology are all suitable and available for application to urban, rural and remote areas of Ontario and other regions of Canada.

35. Questions or comments? For more information: Jessie McGowan jmcgowan@uottawa.ca