Cited by Davidoff and Florance²¹ in 2000 as an innovative “informationist” model, the CICS is a novel approach to advancing clinical librarianship that mitigates many of the previous concerns raised about CML practice. The CICS integrates librarians into clinical rounding teams as expert information providers, equipped with adequately deep background knowledge in both principles of clinical medicine and information seeking. CICS participants can diagnose unexpressed information needs as they occur during practice and prepare relevant, balanced syntheses of the evidence from the medical literature. Since the program's inception, the service has expanded to collaborate with 10 clinical teams.

Eskind Biomedical Library has focused on high-acuity hospital inpatient care units for CICS implementation. Such units provide care for the most critically ill patients and generate complex queries regarding information needs. These environments also encompass the potential for tremendous impact of information on patient outcomes and clinician education at highly meaningful points in time. Targeting these units allows CICS informationists to work in some of the most challenging environments and reach large numbers of clinicians. Residents and fellows undertaking specialty training in almost all areas of clinical practice must now rotate through the hospital critical care units associated with their specialties. The EBL CICS program matches the interests of the librarian-informationists (i.e., their enthusiasm for a particular area of clinical practice) to the specific unit assigned to them. Motivation and enthusiasm figure significantly in determining the success of a clinical informationist in a given field.

Just as the patient's care team must accept caseworkers, nutritionists, pharmacists, and other ancillary specialists as acknowledged experts for them to play vital roles in patient care, clinical informationists at Vanderbilt University Medical Center must establish themselves as legitimate partners in the provision of high-quality health care. The CICS supports best clinical practices through providing, as Pearson advocates,⁷² carefully vetted evidence appraised for its relevance and significance, representing the essence of the literature in a balanced manner.

The CICS efforts required the library to develop a supporting culture of pervasive learning, training, and adapting of skills. For more than a decade, EBL has devoted significant resources to creating an environment that values and engages in lifelong learning. The EBL training infrastructure supports a diversity of roles for librarians, focuses on improved utilization of resources, and has reallocated librarians from reference desk services to collaborations in the medical center without adversely impacting the library's budget.⁶⁹ To prepare themselves for new roles, informationists build their personal knowledge bases in medicine and research design. They enroll as students in Vanderbilt nursing and medical school classes in areas such as biostatistics, anatomy, and physiology. They also participate in case presentations on rounds, attend clinical seminars, complete in-house learning modules, and review journal articles and key textbooks in general medicine and specialty areas.

As implemented in the clinical setting, CICS informationists, upon receiving a complex information request, negotiate a priority level for results delivery with the clinical team. The type and urgency of the need prompting the information request determines the priority. Informationists provide results to the initiating clinical team for acute information needs within a period of several hours; intermediate priority queries within two to three days; and queries with an educational or general information emphasis within seven days.

To respond to information requests, informationists execute and filter searches in a multistep cycle. First, they retrieve a targeted initial group of articles and hand select the most relevant items based on their ward experience–derived understanding of the question and the article's content, thus, taking into consideration the individual patient and hospital unit situation. They then go beyond searching, by reading and filtering the full text of the most appropriate articles, highlighting passages that are relevant to the clinical case at hand. When necessary, prior steps are repeated, including searching for and reading additional articles. When search results yield multiple viewpoints, clinical informationists select the best article representing each viewpoint—analyzing study methodology and quality of execution as well as relevance to clinical context. An analysis of viewpoints represented in EBL-authored evidence summaries indicated that if librarians had stopped searching the literature after finding the first relevant answer, additional relevant viewpoints would have been missed for more than half the treatment-related questions.⁶⁶

Eskind Biomedical Library clinical informationists, in preparing their written reports, synthesize all of the highlighted information from articles into a concise summary. Each summary points out such factors as conflicting recommendations in different articles, strength of the evidence, and facts about a study that differ from the specifics of the clinical case. This summary also includes a disclaimer, jointly authored with the VUMC Office of General Counsel, advising clinicians to consult the full text of the articles (appended to the summary report) before taking action and noting that the summary is not intended to serve as a substitute for clinical judgment. Ultimately, the clinician has the final responsibility for determining whether the evidence applies to a specific patient. Finally, the informationists present their results to the clinical team during rounds, addressing any questions about the evidence that arise during the discussion, and identifying additional information needs as they arise.

Initial subjective evaluation of informationists' performance by clinical team members showed that clinicians consistently rated clinical informationists' ability to function in the clinical environment, as well as the utility of the information they provided, at the highest levels.⁶⁵ In addition, recent research, conducted collaboratively by EBL team members and Vanderbilt's Department of Biomedical Informatics faculty, indicates that informationists identify literature relevant to complex clinical questions as reliably as physicians trained in clinical research. This work suggests that experienced clinical informationists with training in information seeking, literature synthesis techniques, and research design and biostatistics are adequately equipped to function as surrogates for clinicians in selecting relevant evidence for specific information needs.⁷³

Physicians in VUMC's Adult Primary Care Center currently use the existing secure, internal messaging feature of StarPanel⁷⁸ to send patient care questions directly to EBL librarians via “information baskets.” As part of the question submission process, clinicians select from a list of priority levels reflecting the urgency of the information request.

Because CICS librarians are integral components of care delivery teams, they must sign and agree to abide by the same stringent confidentiality measures as clinicians for accessing patient information. Thus, the outpatient StarPanel information queries arrive connected to the patient medical records from which they arise, providing the specific CICS librarian assigned to the case with direct access to the details of the case at hand. Integration of the “outpatient evidence consultation request” function within the electronic health record system overcomes the need for CICS librarians to be omnipresent in less acute outpatient care delivery settings, and diminishes the need for busy health care providers to collect and send the patient-specific details necessary for librarians to provide highly targeted evidence syntheses in response to questions.⁷⁹

The Vanderbilt experience in this project has already demonstrated that CICS librarian access to patient records affords a clear advantage during the patient-specific information evidence synthesis process. For example, in response to the clinical query, “When should one operate on a patient with hyperparathyroidism?” an EBL librarian examined the patient's laboratory values (calcium, phosphate, and other blood counts) and previous radiology reports as well as coexisting diagnoses and related notes from the patient's endocrinologist regarding bone density results. Most importantly, the librarian was able to extract from the literature the specific recommendations for the patient's relatively young age. These details of the nature of the patient's condition equipped the librarian with a powerful means to customize the response to the specific situation without requiring additional time from the clinician making the request. This type of evidence synthesis also becomes a permanent part of the patient's medical record. Upon completion of the question, the information specialist attaches the synthesized packet of information directly to the patient's electronic chart for review by members of the health care team.

Currently, the library has integrated links to more than 750 guidelines within the electronic medical record. Librarians at EBL developed a priority list of key conditions with potential for significant impact by compiling feedback and requests from outpatient physicians and clinic leaders; this list expands with additional topics that come to the forefront. Librarians select and match guidelines from three evidence-based medicine resources (National Guideline Clearinghouse, HealthGate, and UpToDate®) to appropriate ICD-9-CM codes. The resulting EBL-maintained data file of paired ICD-9-CM codes/guidelines interfaces with the StarPanel system. The ICD-9-CM codes from Vanderbilt's patient medical billing records drive the linkage for displaying, within the problem list portion of StarPanel records, the guidelines relevant to the care of individual patients based on their primary condition. For example, a clinician caring for a patient who has received treatment at VUMC for diabetes and hypertension will be connected with key guidelines, such as the 2004 American Diabetes Association standards of care⁸⁷ and the 2003 American College of Physicians recommendations for blood pressure control in diabetics.⁸⁸

Applying expertise gained through participation in clinical rounds, EBL librarians utilize their subject knowledge bases to separate pathway topics into component facets. They then create corresponding expert search strategies for five key online sources of primary and synthesized evidence. Librarians also create overall analyses of the state of the literature as they review the information gained during pathway development. These analyses detail current areas of controversy, the types of studies typically encountered (e.g., few RCT, many retrospective studies) and relevant search terms for further exploration. The expert, topic-specific search strategies as well as librarians' overall analyses for pathways topics reside in the EBL-created Pathway Literature Locator (PLL) database, thereby providing automatically updated access to evidence at the time of need. For example, the team responsible for the maintenance of the “adult splenectomy” pathway utilizes librarian-created search strategies to access evidence on key facets of the topic, ranging from timing of perioperative vaccination to specific considerations in the myriad of indications for splenectomy. The PLL database also accommodates specific questions from pathway team members when more in-depth synthesis of the literature is required, providing a mechanism for contacting the librarian regarding particularly focused aspects of the literature, such as new interventions currently in the exploratory phase of clinical research.