Doctors and other health professionals want mobile access to clinical information for one simple but overwhelming reason: so they can avoid making fatal mistakes on the wards. As a result, some medical librarians have already joined clinicians on their ward rounds, and most are now playing an active part in developing evidence-based medicine resources.

Ann Brice, specialist libraries development manager at the National Electronic Library for Health , says: “Evidence-based medicine (or evidence-based healthcare, as we prefer to call it) has a very high profile among UK health librarians. Librarians were some of the first people to get involved in the movement, as it became clear that skills in asking questions, and finding and appraising the results of research were essential steps – in fact, they underpinned the processes that clinicians, managers and patients needed to undertake to improve their decision-making.

“Librarians are not only asking for evidence-based resources, but are taking a more active role in ensuring that knowledge – that is, the products and services available – is generated using the best available evidence and explicit methods to reduce bias and uncertainty. They are also keen to ensure that resources are written in ways that provide clear, concise answers to the most relevant clinical questions.”

Backdrop of uncertainty

But librarians are driving evidence-based medicine (EBM) against a backdrop of uncertainty. The much criticised NHS IT infrastructure development is still years away from completion. And with content providers bringing to market systems that are often very much under development, access to resources at the bedside is still neither quick nor easy – yet.

In an ideal world, evidence-based medicine would be delivered at the point of care. This world would be populated with doctors and nurses having access to summarised resources from portable devices that provided diagnostic and treatment support, mimicked medical practitioners’ workflow, and were linked to patient records.

That ideal world is some way off. According to the EPS report , Evidence-based Medical Practice in the 21st Century, the move to electronic health records (EHRs) will drive the adoption of evidence-based medicine. EHRs are expected to be in place by 2010, but many hospitals have little if any wireless access.

Betsy Anagnostelis, librarian at the Royal Free Hospital Medical Library , and joint biomedical team leader of UCL Library Services, says: “The most significant factor is whether or not the clinician has easy and speedy access to appropriate current content and that can be a challenge, especially if it requires going online. To be effective, PDAs need to be integrated effortlessly with local IT, and information updating also needs to be as seamless as possible. There is a role for information specialists to provide support in this area.”

The roles that librarians can play to support evidence-based medicine have come in for much debate. The skills that clinicians need to practise EBM include how to formulate relevant questions, efficiently search medical literature and evaluate the evidence for validity and applicability to the patient. Clearly, librarians can help them with that.

“In some cases – for example, in the work of clinical librarians and the information specialists of the NLH specialist libraries, these roles have already changed,” says Brice. “However, there is still work to be done to equip librarians to further change their roles, and be more proactive in developing and promoting these skills. There is also a huge, and as yet untapped, need to support patients and the public to develop skills in finding and interpreting high-quality evidence, and a need to work across the sectors to make this a reality.”

Researchers at Sheffield University have found that in the quest to bring information closer to the point of clinical decision-making, information specialists have adopted outreach or peripatetic roles.

Andrew Booth is senior lecturer in evidence-based healthcare information and director of information resources at the Sheffield-based School of Health and Related Research. He says: “It has become clear that the degree of expertise needed to answer clinical questions by database access, etc, goes well beyond the aspirations of the average doctor. One of the effects of bringing in clinical librarians has been to improve the standards of doctors.

“This is creating a new demand for information professionals. The only issue is sustainability; very often development is in projects of one to two years. The challenge now is to make these newly created positions more routine and mainstream. But it is easier to get funds for projects.”

Integrating the ISIC

The Medical Library Association in the US has carried out extensive research into the new role of the information specialist in context (ISIC). For its recent eponymous report, it surveyed practising ISICs in different scenarios. The aim was to define the ISIC’s role and training needs and set out a strategy for fostering acceptance of the role.

Participants felt that training paths, funding streams and model implementations would hasten adoption of the ISIC role, and that a different skillset applied to the ISIC than to the medical librarian. They also warned that more responsibility meant more liability, with ISICs running the risk of facing legal action for mistakes made as a result of providing wrong info rmation.

In the UK, where the NHS provides most healthcare , budgetary concerns are a bigger barrier to the deployment of ISICs. Anagnostelis says: “At a time when there are pressures on staffing, we have to be careful to focus on services that are able to make the most impact.”

She set up a clinical effectiveness enquiry service at the Royal Free to provide evidence-based resources on demand. Sending out information professionals with clinical teams was not a practical option.

“To set up this service it was necessary to remodel service delivery so as to ensure that staffing was available when needed to provide a responsive service, prioritised according to the urgency of the patient’s case,” she explains. “The service took five years to plan and implement. It was part of the library strategy agreed at the time with our local NHS trust.”

The library is also hoping to link into the award-winning UK/Australia Chasing the Sun project, providing a 24-hour enquiry service.

Anagnostelis continues: “It has not been possible to offer a sustainable presence within clinical teams, except as pilots, or to establish a service. A single information professional is unlikely to be able to reach many clinical teams in a large, multi-speciality hospital, and clinician buy-in to an in-context library service is likely to be variable. With an enquiry service, on the other hand, and by offering mediated searching on demand, and targeted search support and assistance for teams developing clinical guidelines, it is possible to address a far wider range of questions that arise relating to patient care.”

If resources allowed, Anagnostelis would favour integrating some information work into the work environment, at or close to the point of patient care. She says that a team of information specialists is evaluating outreach options.

Who does what?

Evidence-based medicine players include Bazian, Zynx, EMed Group and UpToDate. They, and the big content providers and aggregators, are targeting this emerging market.

Elsevier’s iConsult delivers real-time clinical decision support, while content provider Ovid’s Clin-eguide covers the several hundred disease entities that generate the vast majority of inpatient hospital admissions. For those clinical questions not covered in Clin-eguide, ClinicalResource@Ovid can provide a quick view into the best evidence.

To meet the emerging focus in the NHS on “team” patient planning and treatment, the 5 Minute Consultdata, which is included in the ClinicalResource subscription, contains a specially written section on nursing considerations for every disease it covers.

Patti Corbett, marketing clinical decision support at Ovid, says: “We are currently working on expanding our integration into clinician workflow, going deeper than a simple InfoButton API capability. We are also looking at tablet PCs and wireless technology for delivery.”

Proquest recently moved into the EBM arena with a distribution deal with Evidence Matters. Suzanne BeDell, vice-president of Higher Education Publishing ProQuest, says: “Evidence Matters has ambitious plans in terms of content and we plan to continue to make it more usable and provide more synthesis.”

Many observers are calling for material to be substantially rewritten for PDA access – for example, by providing more synopses and summaries. Experts say that most large publishers now realise that “granular” content is the future. Thomson, for example, has invested a lot of time in making its production system able to source content for a wide variety of products.

The content providers face stiff competition in the UK. The National Library for Health and Medic-to-Medic, developer of the Map of Medicine, have partnered to deliver a programme of work to integrate NLH knowledge resources with the national care records service. “It would be difficult for the available commercial products to compete with that model and remain competitively priced,” says Anagnostelis.

Health librarians no longer find themselves only staffing reference desks or building collections. Emerging roles are surfacing in all arenas and within all these roles information professionals can start to develop medicine as an information profession.