Evidence based health care: diverse career opportunities for librarians
We assume health professionals maintain a current knowledge of research in their field. The volume of research publication in the health science has grown at near exponential rates in recent decades. It has been estimated that a clinician needs to read 17 peer reviewed articles per day, every day of the year, to stay current (Haynes 1993). Even for specialist the task is daunting. Since 1987 over 170,000 articles on cancer have been indexed by the database Medline. The challenge to summarise this research evidence has been taken up by international groups like the Cochrane Collaboration [http://som.flinders.edu.au/FUSA/COCHRANE].
Today I will outline what is Evidence Based Health Care and what roles Librarians are undertaking in this major process of change in health care. I will provide some case examples from my own experience and will introduce you to the challenges of evidence based practice for all Librarians.
1.Evidence Based Health Care
EBHC is a deceptively simple concept but the devil is in the detail. EBHC is an expansion of the concept developed for medicine in the early 1980s. Sackett et al (1996) define EBM as "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external; clinical evidence from systematic research". This approach has migrated from clinical medicine to other health care disciplines variously being defined as "evidence based healthcare" (Gray 1997) and "evidence based practice" (McKibbon 1998). It was in fact Ann McKibbon , a health sciences librarian from McMaster University in Ontario who redefined this approach to encompass the patient's perspective. For her, "Evidence based medicine (EBM) is an approach to health care that promotes the collection, interpretation, and integration of valid, important and applicable patient-reported, clinician-observed and research-derived evidence. The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgements" (McKibbon et al 1995).
Simple, is it not. Just apply the research evidence in the context of your professional judgement and your patient's choices. What happens though when there are 20 million pieces of 'evidence' of varying quality and sometime of contradictory conclusions. Your average consultation time is 7-10 minutes. Practically, how can you access, distil and apply this research? To address these issues a number of approaches have developed. One is to develop summaries of the best available research evidence and another is to train clinicians and other health care decision makers to find and appraise relevant evidence. Other approaches have been to imbed knowledge prompts in software for drug and test orders and for electronic patient records. These are generically called decision support systems. Another story entirely.
As you know any research process requires a review of past studies to provide context. Some research consciously reviews significant past research to provide a useful summary. This type of narrative review is open to a number of sources of bias. The author's personal beliefs, the quality and availability of research papers all bias such summaries of research evidence. To overcome these limitations groups such as the Cochrane Collaboration, the National Centre for Clinical Excellence in the UK and here in Australia, the Centre for Clinical Effectiveness at Monash University have developed more rigorous methodologies.
Using the gold standard research methods of randomised controlled trials, systematic reviews by Cochrane Review Groups identify all published and unpublished randomised control trials (RCTs) on a clinical topic, extract the results data from sound trials and undertake a statistical meta-analysis to produce valid conclusions. As many as 500 trials may be assessed for one such review. These reviews are regularly updated against new research. The Collaboration has identified over a quarter of a million clinical trials and produced nearly 600 systematic reviews. These are published in the Cochrane Library on the Internet and on CD-ROMs. http://www.update-software.com/cochrane/ There are also other evidence summaries available on the Internet from a variety of international sources. An excellent gateway to these can be found at Andrew Booth's web site Netting the Evidence: http://www.shef.ac.uk/~scharr/ir/netting/. Andrew is a another health Librarian who has made a substantial impact in this field.
Evidence based practice requires practitioners to have the skills to access and interpret evidence. This specialist informatics skills training is an increasingly common role for health librarians. Under the logo of Ask>Find>Appraise>Act>Evaluate librarians for the UK Anglia and Oxford National Health Service have developed Finding the Evidence Workshop (FEW) and Critical Appraisal Skills Program (CASP) which have been adopted and adapted around the world. Details of these programs can be found at http://libsun1.jr2.ox.ac.uk/caspfew/ There are an increasing number of Australian health librarians involved in this type of training.
2. Role of Librarians as Information Clinicians
This type of informatics skills training is nothing new for librarians. What is new is the advanced level required by end users and the diversity of information sources covered. Medline searches of 60 lines are not uncommon. These are often replicated over a number of health sciences citation databases. Critical appraisal skills training requires a detailed knowledge of research methodology and statistical techniques.
As well as designing and delivering education and training programs in both academic and clinical setting, librarians are involved in designing developing interactive web sites and software tools. Some Cochrane Review groups include librarians as research partners, while other group are merely demanding customers of their local hospital libraries. Librarians are also involved in EBHC at policy and administrative levels. Examples are the appointment of an executive Library Adviser to the U.K. National Health Services and a recent Deputy Director of the Australasian Cochrane Centre being a former public librarian.
Library professionals are increasingly being employed under different job titles. You will all know examples of qualified librarians working as research officers, project managers, archive and record managers. Some novel examples from the health field are Information Clinician, Medical Informatics Tutor, EBM Educator. A recent article from the leading medical journal Annals of Internal Medicine, called for the creation of a new professional speciality called the Informationist, a discipline requiring a combinations of the skills of a librarians, a clinical epidemiologist and a medical scientist (Davidoff & Florance 2000). While there is long history of clinical librarianship, ie working from the hospital wards (Lamb 1974, Marshall & Hamilton 1978, Giuse et al 1998, ), the evolving paradigm of EBHC has generated plenty of role reflection among health librarians (Lusher 1999, Scherrer & Dorsch 1999). While some reflect others, to plagiarise a marketing jingle, Just Do It.
My own experience as Chair and Project Manager from the South Australian Human Services Libraries Consortium provides some local examples for the role of librarians in promoting EBHC as an industry knowledge management strategy (Fowler 1998b, Fowler 1999). As Facillitator of the ALIA Health Section Continuing Professional Development for Evidence Based Health Care Group, I am also actively working to improve my own skills, and those of my peers, as an information professional in this field. (Fennessy 1999). The SA Health Librarian Section ran a National Train the Trainer Workshop in 1998 as part of this professional development process (Fowler 1998a).
3. Some future trends
The effort of the Cochrane Collaboration in preparing and maintaining systematic reviews of health care interventions are now being replicated for education and the social sciences. The Campbell Collaboration is "an emerging international effort that aims to help people make well-informed decisions by preparing, maintaining, and promoting access to systematic reviews of studies on the effects of social and educational policies and practices". http://campbell.gse.upenn.edu/intro.html I would encourage you to seek opportunities to contribute to the work of this organisation.
In closing I would like to draw your attention to the application of the process of evidence based practice to librarianship in general. A recent paper by Julie Hooke in LASIE (Hooke 1999) and a presentation by Andrew Booth (Booth 2000) at the Library and Information Association of New Zealand Aotearoa annual conference in Christchurch, New Zealand earlier this month are I believe the beginnings of a new phase in the professionalism of our practice. I also eagerly await, as someone sentenced to life long learning, a paper by Elderidge (in press) due out next month.
The key issue for the profession is 'Do we have the research base upon which to build evidence based practice?' Today, sadly I feel the answer is No. The next question is then how do we enthuse the next generation of librarians to build evidence based practice? I hope I have made some small contribution today.
Booth, A (2000) Exceeding expectations: achieving professional excellence by getting research into practice. Library and Information Association of New Zealand Aotearoa Conference Proceedings. Christchurch, New Zealand. 15-18 October 2000 http://www.conference.co.nz/lianza2000/papers.html
Davidoff, F. & Florance,V. (2000) The Informationist: A New Health Profession? Annals of Internal Medicine, 132: 996-998.
Elderidge, J (in press) Evidence-based librarianship: an overview. Bulletin of the Medical Library Association, October 2000.
Fowler, G. (1999) Health Libraries and Knowledge Based Decision Support Systems. Proceedings of the Australian Library and Information Association 5th Biennial Conference and Exhibition: Pathways to Knowledge. Adelaide, October 1998.
Fowler, G. (1998a) National Train-the-Trainer Workshop Kit. The Cochrane Library and Evidence-Based Health Care. Adelaide: ALIA Health Section and Australasian Cochrane Centre.
Fowler, G. (1998b) Knowledge Based Decision Support Systems in the SA Health Enterprise. First National Decision Support Systems Conference, Adelaide, March 1998.
Gray, JAM (1997) Evidence-based healthcare. Edinburgh: Churchill Livingstone.
Giuse, NB., Kafantaris, SR. Miller, MD. et al.(1998) Clinical medical librarianship: the Vanderbilt experience. Bulletin of the Medical Library Association 86(3), 412-416.
Haynes, R. (1993) Where's the meat in clinical journals? ACP Journal Club, 119: A23-4.
Hooke, J (1999) Evidence-based practice and its relevance to library and information services. LASIE September: 23-34
Lamb, G. (1974) And now clinical librarians on rounds. Journal of the American Medical Association, 230 (4), 521.
Lusher, A. (1999) Getting evidence to the bedside: role of the clinical librarian. Libraries without limits: changing needs-changing roles. Proceedings of the 6th European Conference of Medical and Health Libraries, Utretch 22-27th June 1998 Dordicht: Klewer
Marshall,J.G & Hamilton, J.D. 1978, (1978) The clinical librarian and the patient: report of a project at McMaster University Medical Center. Bulletin of the Medical Library Association, 66(4) 420-425
McKibbon, KA (1998) Evidence based practice. Bulletin of the Medical Library Association. 86(3) 396-401.
McKibbon, KA, Wilczynski, N, Hayward, RS, Walker Dilks, CK & Haynes, RB (1995) The medical literature as a resource for health care practice. Journal of the American Society of Information Science 46(1) 737-742
Sackett, D., Rosenberg, W, Muir Gray, J., Haynes, R, & Richardson, W. (1996) Evidence based medicine: what is it and what it isn't.. British Medical Journal. 312: 71-72. Also WWW document: URL - [http://cebm.jr2.ox.ac.uk/ebmisisnt.html]
Scherrer, CS & Dorsch, JL (1999) The evolving role of the librarian in evidence-based medicine. Bulletin of the Medical Library Association 87(3) 322-328.
Last modified: 2001-03-04