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STRAIT to the future8th Asia-Pacific Specials, Health and Law Librarians Conference Clinical Information Access Project - revolution for information professionals
Gillian Wood Keywords: Online Information AbstractIt is almost three years since the Clinical Information Access Project (CIAP) was first conceived. The Project was designed to harness the power of distributed information provided by the Internet; and the availability of clinical databases such as Medline and CINAHL. The goal was to provide all 50 000 clinicians in the NSW Public Health System with decision support information at the point of care - on the ward, in the clinic - 24 hours a day. While the technology existed in theory, the practice was untried, and the Project was a pioneering experiment. This is a look at the establishment of the CIAP, highlighting some of the barriers and issues concerned with this ground-breaking project. In particular, it looks at the issues this project raised for librarians, who were involved with, but not directing, the information delivery to clinicians. IntroductionThe advent of wide-spread access to online information sources has been a great boon to libraries and their clients. However, it has also forced librarians to re-think what they are doing and the way they are doing it. This is particularly so in NSW Health, where an innovative service was introduced by clinicians for clinicians, with the impact on libraries and librarians not considered as a main feature of the service's design. After two years, the Clinical Information Access Project is being lauded by clinicians and librarians alike in providing information to end users; and librarians are working out their role in relationship to it. The Clinical Information Access ProjectWith the advent of the Internet, librarians quickly realised its potential for sharing information widely, regardless of geographical boundaries. The number of health web sites and sources of health information are rapidly increasing, and Coiera (1997) suggests that this is as much an indicator of the large previously unmet need as of their capacity to fill that need. In NSW, the Clinical Systems Steering Committee (CSSC) realised the need for a clinical decision support system at the point of care, available 24 hours, seven days each week. It was recognised that clinicians were being burdened with uncoordinated systems, often making it difficult to located needed information in a timely or efficient manner. From the outset, this project was driven by the CSSC as a clinical support system for clinicians, managed by clinicians. Whilst librarians were represented on the steering committee from the outset, and were consulted from the earliest stages of the project, this initiative was driven by clinical information imperatives. A committee was convened to oversee the Project, including both clinical representatives and librarians. One of the first tasks was a pre-implementation survey of clinicians across NSW to ascertain the long-term needs of information resources for the site. The survey generated 2795 responses, and demonstrated a high level of computer literacy amongst clinicians, and that the resources identified by the committee were consistent with the needs of clinicians. The information goals of the CIAP were developed to be:
To this end, the resources on the website have grown, and fall into two categories: commercial products (e.g. databases, published books); health system policies, protocols, guidelines etc. In addition, links and communication is another important function served by the website. The commercial content was put to Tender in 1999, and a consortium of Ovid Technologies and HCN provide the majority of this content. Resources currently available include:
Whilst the CIAP content was provided and resourced centrally, utilising existing telecommunications infrastructure, it was realised that barriers existed. These included:
To promote the Project from the start, clinical representatives were appointed in each Area Health Service, and librarians were tied in as key resources people, with a deep knowledge of the databases, advanced searching skills, and access to additional information resources. Impact on librariansFrom the outset, the Project was reliant on the skills and advice of librarians, and a number now contribute regularly as members of the Steering Committee. It was acknowledged from the start that librarians in each Area would be key resource people for the Project. However, the Project remained clinically driven, with selections of resources and methods of delivery focussing on clinicians. One early example of the differing priorities was that of a user-friendly search interface. The Ovid interface automatically maps to a thesaurus term, and guides the user into building a more thorough search. However, this was frustrating (and slow) for expert searchers. But the bottom line remained that it was the clinicians (who loved the interface) whose needs and responses directed the project, and librarians were trained in shortcuts on the system. It is interesting that this is the ultimate in customer focus - actually having the customers design and run the system themselves. Initially, the major impact on librarians was in additional workload, as they undertook training, processed increased inter-library loan requests, and answered myriad questions, both about the information and about technical aspects of the project. For many librarians, there was a slow connection to the Internet to be overcome, and a different interface to the one they were already using. In addition, the first year of the Project's operation was as a pilot, so there was no guarantee that the databases would be available or funded past that period. A major difficulty for many librarians was actually getting access to the Project's resources. The Project had been established with the knowledge that optimal connectivity was not available in many areas, in the hope that it would promote the need to connect to the Internet. Initially, some places had grave doubts about the security risks involved with connecting hospital networks to the Internet; and doubts about giving all clinical personnel this access. In time, this has been gradually resolved, with Intranet access to the databases also available. This has also become the spur to get some smaller libraries connected to the Internet. Some difficulties remain, particularly where conflicts between networks or firewall issues occur, and these must be addressed at an Area level. Additionally, feedback also suggests that a large proportion of CIAP searching is undertaken from the clinician's home, after hours, and not at the workplace. This is another bonus of the flexible system. One of the first questions to be confronted by librarians was that of the role of their library in this new scheme. The CIAP team have always been unequivocal in their opinion that the Project was an adjunct to libraries, not an alternative, however the provision of the suite of databases could have encouraged some to think the library was redundant. Fortunately, the libraries have found many opportunities for growth in their role in their hospitals. Firstly, the Project overcame one of the great difficulties of libraries, namely that they were not available 24 hours. With key clinical information always at hand, this was crucial, particularly to remote clinicians. Moreover, the Project is designed to increase the information culture within the staff of NSW Health, and the demand for further information is insatiable. To overcome fears of poor searching, many librarians have become key links in their hospital's use of the CIAP, answering questions and providing training. The provision of full-text journals has provided another challenge, with libraries having to think about the future of their hard-copy subscriptions, meanwhile grappling with the nature and quality of the electronic version. One particular difficulty, that of printing graphics, has demonstrated that "e-journals" are not always the total solution to everything. In addition, whilst their currency is improving, the inclusion of some full-text can lag weeks behind the hard copy, which may be unacceptable for some clinicians and researchers. One advantage of the Ovid system, however, is that the data is owned by NSW Health, and could be locally mounted, should the subscription cease. In this way, the subscription is still to ownership, not just access rights for the journals. The issue of funding is one which is still to be fully resolved. Approval was given for the costs of the databases to be paid centrally, with each section of NSW Health contributing according to the standard Resource Distribution Formula (RDF). This principle was designed to separate access to the information from the cost of providing that information, encouraging an information-rich culture. Unfortunately, in some sectors there were attempts to have libraries pay some or all of their institution's contribution, an amount far beyond their means. The CIAP team have been working with administrators to try to ensure that payment is from appropriate funds, and that libraries are not penalised for this breadth of information. Another key issue is integrating the CIAP with local collections. It is possible to link from some of the reference databases to a Z39.50 compliant OPAC, or to match journal titles with a local holdings statement. This requires additional work from both the libraries and the host of the databases, but is an essential part for the future of the Project. Further work on directing people to their libraries if they cannot fill their information needs from the CIAP is continuing. This is being enhanced by a newly-formed advisory group of librarians. This group has been formed to allow librarians to discuss how they can best integrate the CIAP into their library, and use it to improve their service to their clients. Recommendations from this group will be taken to the Steering Committee. A commentary on some of these issues has been raised (Kammerman, 1999), highlighting the need for the CIAP to continue to evolve, and for libraries to work within their local situation to address their issues. One key point raised is the stability not only of the CIAP but also of all electronic access to information. Whilst disaster-planning has been addressed more recently with the potential advent of the Y2K bug, it is an essential for us all to be aware of as more and more of our services become dependent on technology. Likewise, there is a large element of trust in relying on others for key resources, as is increasingly happening with the CIAP. Whilst the core resources were suggested by clinicians, there are always more resources being requested. This is a future challenge for the Project, which this year has one database (PsychInfo) sponsored by the NSW Centre for Mental Health as part of their efforts in improving mental health care across NSW. The option for other databases to be added locally also exists, with the possibility of adding resources which can only be seen from specific logins. This aspect is yet to be fully explored, as part of tailoring the Project more efficiently to specific clinicians' needs. ConclusionIt is inevitable that we will increasingly rely on electronic resources for our information. It is clear that our clients are beginning to expect instant gratification at their desktop, and that this is a goal worth pursuing. The CIAP began with a concept of providing information to all clinicians in NSW in a format desirable to many, and waiting for the requisite technology and systems to fall into place. The Project has now become an integral part of the information culture of the organisation, with many of the early technical problems being resolved. However, there is great scope for librarians to harness even more of the potential offered by this Project, in which they are an integral, but not driving, part. As we head towards the future, NSW Health has a tremendous resource available to it, and it is up to us to continue to work with it to further the advances which have given clinicians this decision support material at their fingertips. Author
Gillian Wood, BA (Hons), Dip I.M. (Lib), Library Manager, NSW Health Department
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