The type, format, and sources of information in medicine are undergoing significant and rapid change. The increasing number and diversity of useful medical electronic databases and Internet sites owe their existence in large part to the growing body of evidence-based literature that seeks to connect clinicians with systematic observations from medical research. Medical librarians, in addition to their role in archiving information, are now focusing on providing more effective methods of information retrieval, usually through electronic means.
To meet the growing demand for electronic “just-in-time” information, many librarians are encouraging their users to build their own personalized portals to library home pages for quick access to the resources and services they use the most. Librarians are also looking to handheld computers to provide this information in a clinical setting.
These new retrieval systems also have the potential to provide new types of information, information that synthesizes “raw” information originating from original research findings into summaries and conclusions. Librarians are increasingly being asked to provide information that is filtered by scientific rigor and relevance to the clinical practice of medicine [1–4
]. Information sources that evaluate the rigor and relevance of information and then summarize it in the form of synthesized answers to clinical questions can be very helpful in meeting this goal.
Summary sources of information have existed for some time, usually in the form of books, reviews, consensus reports, and expert statements from professional organizations. This new type of information differs from these older sources in that it strives to provide information that is more useful to clinicians in the day-to-day care of patients.
The needs of clinicians in practice are quite distinct from the needs of students, researchers, or nonclinical hospital or university personnel [5
]. Clinicians usually seek information for two reasons: to stay current with new developments in medicine relevant to their practice or to find answers to patient-specific questions [6
]. Different tools and methods are required for these different information needs. Clinicians need to be told about new information but also need a tool for quickly finding the information again when they need it.
Due to the time constraints imposed by medical practice, the usefulness of information retrieval systems and the information they provide are critical to busy clinicians. Clinicians generate highly specific patient-related questions at a rate of about one to three questions for every three patient visits [7
]. Of every ten questions posed, they only look up the answers to four and only find the answers to three [9
]. Of those they do not look up, they estimate at least half are important. Thus, clinicians are guessing at seven of ten questions, due in large part to the amount of work it takes to find valid and reliable information that applies to their patients.
The traditional evidence-based medicine (EBM) approach focuses mainly on the critical evaluation of original research and other sources of primary information. Over the past several years, many librarians have become active partners in the EBM process by expanding their skills to include a better understanding of clinical research and its resulting literature [10
]. Librarians are now teaching targeted searching techniques, quality filtering, and critical appraisal skills in their organizations [11
]. However, this approach—the evaluation of the validity of medical information by individuals using it, whether by librarians or clinicians—is not as useful as it could be because of the excessive time involved and difficulty of integrating it into clinical medical practice at the point of need. Original research, as typically published, is not useful in the care of patients until it has been transformed in some manner.
The “usefulness” of any information source rests on the three characteristics outlined in this equation [12
The validity of information refers to its scientific rigor (). A hierarchy exists of research study design, with some methodologies having greater scientific strength. The randomized controlled trial is the strongest type of design in clinical medicine. Even randomized trials may have design faults, and critical appraisal techniques have been developed to evaluate the validity of this type of research [13
Table 1 Assessing the validity of information sources
Information in the medical literature also has various levels of relevance to practitioners of clinical medicine. The goal of medical practice is to help patients live long, healthy, functional, and symptom-free lives [14
]. The most relevant information is research that directly
evaluates the effectiveness of medical care on these outcomes that matter the most to patients.
This type of information is called “patient-oriented evidence that matters” (POEMs) [15
]. This type of evidence evaluates the effectiveness of interventions that patients care about and that, as a result, clinicians care about as well. Most information in medicine, including most research, is preliminary in that it does not directly address the question of whether a particular medical approach is in the best interest of patients. POEMs contains information that directly tells clinicians that what they do for patients has been shown to make them live longer or live better.
For example, for many years anti-arrhythmic drugs were used to treat patients with asymptomatic cardiac ventricular arrhythmias because of their demonstrated effect on diminishing the frequency of arrhythmia. The supposition was that decreasing these arrhythmias would decrease patients' risk of sudden death, frequently the result of uncontrolled arrhythmic activity. After six years of use, the first study was performed to determine whether mortality was decreased in these patients. Much to everyone's surprise, mortality was actually significantly increased compared with untreated patients. This study was replicated several times, with the same results, and these drugs are used much less today.
This is just one example in which the preliminary information is not supported by research evaluating patient-oriented outcomes. There are many instances in which the early, “makes sense” data did not translate into benefits to patients. While this preliminary information is necessary to increase our knowledge of disease, it is “not ready for prime time” in the sense that clinicians should not base changes in practice on it. While this type of disease-oriented evidence (DOE) research is crucial to the development of better medical practice, it is not sufficient, in itself, for clinical decision making.
The goal of this new approach to medical information is to provide highly valid and relevant information while requiring the least amount of time and effort to locate and apply it to practice. To meet this goal, these new information sources have the opposite focus of many other information tools in that they strive to provide less information rather than more.