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A bill designed to improve health care access and quality for all citizens of Washington State was passed and signed into law in May 2007 . Many of the bill's provisions stemmed directly from recommendations made by the governor's Blue Ribbon Commission on Health Care Costs and Access. One of the commission's recommendations was that health care providers follow evidence-based standards of practice, where available. This recommendation was incorporated into law by mandating that the University of Washington (UW) Health Sciences Library (HSL) develop a web portal where eligible providers across the state could access evidence-based information to support patient care. To fund this portal, the law required that the Washington State Department of Health (DOH) impose a maximum $25 per year add-on to the license fees of health care providers.* State associations representing licensed care providers were contacted by legislative staff about whether or not their members should be covered by this legislation. Based on those efforts, 14 professions were named in the enabling legislation, totaling more than 150,000 providers (Table 1). A number of other professional groups either were not considered, could not be contacted in the limited time available, or, in the case of pharmacists and dentists, decided on behalf of their members to opt out. A contract was negotiated between DOH and HSL in 2008 covering the development and maintenance of the web portal and the transfer of fees to support this work. The DOH-HSL contract runs through June 30, 2011. The enabling legislation does not sunset.
The HSL hired an experienced medical librarian to develop this program in November 2007. By that time the program had become known as HEAL-WA: Health Evidence Resource for Washington State <http://www.heal-wa.org>. Prior to resource selection and site development, librarians conducted surveys and informal interviews with health providers in the three professions with the largest representation (physicians, registered nurses, and massage therapists) to learn about their information-seeking patterns as well as their familiarity with and use of electronic health information resources. Librarians at other educational institutions, including those in complementary and alternative medicine, were consulted about resources in their respective fields. Because of the diversity of included professional groups, particular effort was made to select resources that would be of value to the broadest number of users. In light of the legislative mandate, resources were also selected, as far as possible, on the basis of their ease of use at the point of care.
Plone , an open-source content management system (CMS), was selected as the platform for the HEAL-WA portal. A CMS was chosen rather than a static hypertext markup language (HTML) site, because the CMS provided greater flexibility in categorizing content, along with greater ease of maintenance. Initial site design was based on that of other sites that group resources by type, content, and targeted users, including HealthLinks, the HSL website <http://healthlinks.washington.edu>.
As the state agency governing the licensing of health professionals, DOH was a key player in making HEAL-WA a reality. DOH and HSL worked for several months in collaboration with the central UW technology services unit to develop work agreements that would cover the transfer of eligible users' data from DOH to UW to be used for authentication purposes, as well as the transfer of fees collected. The work agreements addressed concerns about privacy and appropriate use of user data, data transfer methods, and frequency.
The HEAL-WA site was launched on January 1, 2009. One year after the site's launch, approximately 4% (6,100) of roughly 150,000 eligible users had registered for a user ID. Daily site use statistics show gradually increasing traffic. Aside from the site's main page, the Physician, Registered Nurse, and Mental Health Professionals' Toolkit pages are viewed more than other pages.
Communication with providers about HEAL-WA began on an awkward note. As providers received their license renewals with the add-on fee in mid-2008, many expressed resentment about having to pay the fee and doubts about the portal's usefulness to their practice, especially because the portal was not yet available. Early information about the program from several sources had given many providers the impression that HEAL-WA would provide remote access to the UW HSL's entire electronic collection, which was contractually impossible. However, this misunderstanding contributed to professionals' antipathy toward the program and the license fee add-on. Besides individual providers, the lobbyists for a few of the professional associations have been vocal and persistent with both the legislature and DOH about decreasing or eliminating the HEAL-WA fee or removing their provider group from the program. These professional groups represent, in most cases, a minority of the eligible licensed care providers in the state, but their access to the legislature is formidable and presents a significant challenge to the program.
Because HEAL-WA was a unique resource with a previously untried user model, negotiating contracts for resources presented challenges. Vendors were uncertain about how to structure pricing given the unusually large number of potential users and the unknown number that would eventually use the licensed resources. After discussion with selected resource providers, HSL was able to negotiate favorable contracts for a number of licensed summary and bibliographic databases, some of which included full-text journal access (Table 2). Negotiating access to additional full-text journals has been more difficult, likely due to publishers' concerns about potential loss of individual subscriptions.
Health sciences librarians around the state expressed concerns that HEAL-WA could adversely affect their budgets or their staffing. Those reservations were amplified during the project's early stages by misunderstandings such as the impression that HEAL-WA would provide access to UW Libraries' resources. One misstep was a survey sent to physicians by the state medical association that referred to HEAL-WA, prior to staff notifying librarians that the survey was about to be distributed. This increased librarians' concerns about the effect HEAL-WA would have on their services. Communication with librarians has improved since that time. HEAL-WA has been a featured topic at several meetings of various librarians' associations. There is now an email list that staff use to inform librarians about HEAL-WA updates as well as any impending publicity about the portal. Health sciences librarians in Washington State also have access to HEAL-WA for training and demonstration purposes.
Because HEAL-WA originated with the Washington State Legislature, any changes to the program, including the amount of the fee or which professions are eligible, must go through the legislative process. Staff monitor legislative activity closely and spent significant time during the 2009 and 2010 sessions responding to legislative actions and proposed bills that could affect HEAL-WA.
User feedback has indicated the layout and structure are not intuitive for this new audience. Users' comments have focused on the difficulty of choosing among many links, uncertainty in selecting what resources to use from the available options, and inconvenience of having to perform multiple searches in different resources to find information. Given these comments, a redesign of the site is in progress that will simplify its appearance and include a prominent federated search function to facilitate users' ability to access the resources.
Although HEAL-WA had access to postal mailing addresses for all eligible professionals, publicity efforts were hindered by lack of access to email addresses for most eligible professionals. DOH uses a legacy database system for professional licensing and did not begin routinely collecting email addresses for its licensees until around the time HEAL-WA was implemented. Because there was no cost-effective, efficient way to contact every potential user and because first-year funding was directed primarily toward obtaining the resources that would populate the site, publicity during the critical first year was severely limited. A comprehensive publicity plan has now been developed to increase professionals' awareness of this resource and encourage increased use. HSL has contracted professional marketing services to implement this plan.
Education and training in the use of individual resources is necessary, as the level of information literacy varies widely among providers, depending on many factors. Based on in-person and website feedback, many of the professionals who are the most vocal and resistant to paying the add-on to their license fees do not understand why evidence-based resources are of value. Staff are offering training sessions through hospitals, focusing on those institutions that do not have library services, and given the geographic dispersion of HEAL-WA users, online tutorials will be made available as well. Staff are alert to other opportunities to promote HEAL-WA as a support to the specific information needs of care providers. For example, a new initiative from the state nursing commission would reinstate a continuing education requirement for registered nurses. HEAL-WA provides access to many continuing education modules and will be promoted as a support to registered nurses in obtaining the required hours.
There are several considerations in developing a statewide program of this kind. Major considerations are the source and procedure for obtaining funding. Working directly with a state's professional licensing agency has the advantage of reaching every eligible practitioner and can work well, once procedures are developed to transmit both the designated funds and the necessary data about eligible users for authentication purposes.
Negotiations with publishers were facilitated by providing representatives with clear descriptions of the nature of the project and as much information as was available at any given time about numbers of eligible professionals, emphasizing the pilot status of the project, and highlighting the fact that user numbers would not likely approach the total number of eligible users within the first several years, if ever. A concurrent-users option was available from some publishers and was taken advantage of. Usage will be monitored, and this will be adjusted in later contracts if usage exceeds the contracted numbers. Staff will examine user numbers for all resources to compare pricing with actual use when negotiating future contracts.
Publicity should begin well ahead of the initiation of such a program, continue well after its launch, and highlight other elements, in addition to the evidence-based resources, that affected professionals might see as benefits, for example, access to patient education materials and continuing education credits. Getting support ahead of time from a more representative sampling of the affected parties would be ideal in developing similar programs and could enhance early publicity efforts. Because legislative staff worked with health professional associations to determine which provider groups would be included, and not directly with affected providers, that was not an option in this case.
Health sciences librarians throughout the state need to be considered in early publicity efforts as well. Those publicity efforts should emphasize the value-added services that professional librarians can deliver not only in clinical care but also in administrative decision making, patient safety and risk management issues, and many other areas. It has also been important to emphasize to librarians that HEAL-WA will not be made available as a substitute for an institutional purchase of resources, that institutional access to HEAL-WA will not be given, and that HEAL-WA access does not include access to UW HSL resources.
Despite the challenges encountered in developing and launching this program, HEAL-WA has enormous potential to benefit health care providers, particularly those in underserved areas, and improve patient care for the citizens of Washington State.
*This surprising convergence of events came about due largely to connections between Sherrilynne Fuller, FMLA, then University of Washington Health Sciences Library director; the then president of the state medical association; members of the governor's staff; and an enlightened nurse legislator.