The call for studies to investigate how physicians use online evidence systems and the impact of these on patient care has been consistent since the 1990s,14,15,21
yet to date, the small number of studies conducted have relied almost entirely on results from physician surveys.15,17,22
The present study adopted a unique approach to this problem by examining in detail patterns of online evidence use and their relationship to patient admissions across a large clinician population.
The results showed that “actual” patterns of use, as measured by computer logs, supported the hypothesis that clinicians seek evidence to support patient care decisions. We found that patterns of online evidence use supported hypothesis 1 with the greatest use of CIAP occurring during the core working days and times, with most searches originating from hospitals. Over 40% of clinicians reported that they had direct experience of CIAP use resulting in improved patient care.
The pattern of hospital CIAP use during the week did not support hypothesis 2, which posited that use was primarily related to research and continuing education, and thus a reasonably even distribution of evidence use across the day, with greater use in the early evenings, would be apparent. In contrast, the pattern of online evidence use at clinicians' homes over the same weekday period closely matched hypothesis 2. Both home and hospital weekend use of the online evidence resources also more closely fitted hypothesis 2's pattern of use. Consequently, a mixed pattern of evidence use emerges, with clinically driven searching occurring during contact with patients, and educational- or research-motivated access occurring at other times.
The most significant finding was the strong positive relationship between patient admissions across the state and bibliographic sessions undertaken using CIAP. This correlation was found for the state as a whole and for each of the ten individual hospitals examined. This result cannot be explained by factors such as variation in staffing levels because these, particularly medical staffing, remain relatively constant across the weekdays in public hospitals.
These results are the first step in demonstrating that access to online clinical information is prompted by patient care questions and thus does have the potential to influence clinical decisions. Further work is required to demonstrate the clinical impact of information retrieval on decision making and patient care, and we are undertaking further studies to investigate these issues. However, the continued increase in use of CIAP four years since initial implementation23
suggests that clinicians believe it has clinical use. This view is supported by our survey results, and those of others, in which considerable proportions of clinicians reported access to online evidence as resulting in changes to patient care.15,16
Examination of the reasons for CIAP use showed that CIAP was used to support a range of clinical tasks as well as research and personal education activities. Although 75% reported clinical reasons for use, nearly 60% reported use for personal education and 46% for research. There were professional differences in use for some of the major categories, with doctors more likely to nominate use related to patient care compared with nursing staff. In many instances, these differences reflect differences in their clinical roles. The survey results gave an indication of the wide range of reasons why clinicians used CIAP but did not provide a measure of the frequency of use for specific activities. These findings are consistent with the case study data of clinicians' use of CIAP in which doctors were found to talk predominantly about the use of CIAP to answer clinical questions arising from diagnosis and treatment of individual patients, and nurses focused more on its use to support personal education.18
Nurses in the case studies raised issues regarding “… whether it was the nurse's role to initiate information seeking related to patient care” because doctors were the ultimate decision makers. Such views assist in explaining the smaller proportion of nurses reporting use of CIAP for patient care activities.18
Web-log data, which reflect actual use of clinical information systems, are a much underused resource in researching the information needs of clinicians. We supplemented these data with survey data of clinicians “reported” use and found consistency between sources. The random selection of the hospitals surveyed and the large, completed survey sample size negated many of the limitations of previous studies in this area that have relied on small, single-institution clinician survey samples. The Web-log data identified organizational users but not individuals. However, the survey results demonstrated that use was not confined to a small group of active clinician users, with 47% of all clinicians (75% of those who were aware of the system) reporting use of CIAP, and the majority undertaking searches at least once every two weeks.
Evidence-based concepts have been most influential in the medical profession. In general, nurses have been shown to be low users of research literature24
and to access online bibliographic databases less than doctors but more than allied health professionals.25
Thus, it is likely that if we had included only doctors in our study of online evidence use, overall utilization rates would have been higher. This was confirmed by the survey findings, in which nurses reported lower rates of CIAP use.
Use of CIAP was not consistent across the state, with considerable variation in CIAP rates between hospitals. Technical factors such as access to, and speed of, computers explain only a proportion of the variation in CIAP uptake.18
However, as other research on the adoption of evidence into practice has demonstrated, multiple organizational, professional, and education factors play important roles in determining uptake.26,27
The influence of these variables on clinicians' adoption of online evidence systems warrants further study to maximize the effective use of these systems.