Information Seeking Information Seeking Behavior of PhysiciansBehavior of Physicians

Patti ReynoldsPatti Reynolds

Director, Bishopric Medical LibraryDirector, Bishopric Medical LibrarySarasota Memorial HospitalSarasota Memorial Hospital

Critical SkillsCritical Skills

““Using technology to access clinical Using technology to access clinical information has become a critical skill information has become a critical skill for family physicians.” for family physicians.”

““Family physicians information seeking Family physicians information seeking behaviors: a survey comparison with behaviors: a survey comparison with other specialties”other specialties”20052005

BMC Medical Information and Decision Making 2005BMC Medical Information and Decision Making 2005

Family Physicians NeedsFamily Physicians Needs

Timely access to wide variety of Timely access to wide variety of clinical information sourcesclinical information sources

Specific questions on patient Specific questions on patient management:management:• 3.2 questions for every 10 patients seen3.2 questions for every 10 patients seen• Drug questions most oftenDrug questions most often

Pursuing answers occurs only about Pursuing answers occurs only about a thirda third of the time of the time

Pursuing an answerPursuing an answer

Motivation:Motivation:• Belief that a definitive answer existsBelief that a definitive answer exists• The patient’s problem is urgentThe patient’s problem is urgent

What happens when personal bias or What happens when personal bias or negative attitudes enters the negative attitudes enters the picture?picture?

Where are the answers?Where are the answers?

Half the questions may be readily Half the questions may be readily answered by information in a clinical answered by information in a clinical recordrecord

One quarter of questions require One quarter of questions require traditional resources – books, journalstraditional resources – books, journals

One quarter of the questions require One quarter of the questions require synthesis of information about a synthesis of information about a specific patient with a biomedical specific patient with a biomedical knowledge baseknowledge base

Success Needs…Success Needs… Essential to find accurate information Essential to find accurate information

quicklyquickly Family MD’s spend on average less Family MD’s spend on average less

than 2 minutes finding an answer in a than 2 minutes finding an answer in a text book or journaltext book or journal

MD’s found drug info in a palm pilot in MD’s found drug info in a palm pilot in 20 seconds20 seconds

One study – PDA’s used in 64% of One study – PDA’s used in 64% of outpatient facilities, with 69% looking outpatient facilities, with 69% looking up drug infoup drug info

ResultsResults

Care may be fragmented or Care may be fragmented or diminished and less evidence-based diminished and less evidence-based when access is not readily available when access is not readily available or available only through specialistsor available only through specialists

Study resultsStudy results

457 family physicians457 family physicians• 72.7% male72.7% male• 27.4% female27.4% female• 39.6% practiced in rural areas39.6% practiced in rural areas• 44.8% graduated from medical school 44.8% graduated from medical school

more than 20 years earliermore than 20 years earlier

ResultsResults

59% regularly use the internet daily 59% regularly use the internet daily or weekly for clinical informationor weekly for clinical information

Also use for personal emailAlso use for personal email 47% report access by modem47% report access by modem Journals were rated first in Journals were rated first in

importanceimportance 73% believed that the Internet was 73% believed that the Internet was

useful and important to physiciansuseful and important to physicians

ResultsResults

54% of md’s were confident in using 54% of md’s were confident in using the internetthe internet

14% not confident at all14% not confident at all Family md’s look for info on a specific Family md’s look for info on a specific

patient problempatient problem• Diagnosis/management – 73%Diagnosis/management – 73%• Patient education - 58%Patient education - 58%• Guideline summaries – 49%Guideline summaries – 49%

Specialists were similar but 37% Specialists were similar but 37% looked for patient education materiallooked for patient education material

Credibility and relevanceCredibility and relevance

Credibility was ranked as the most Credibility was ranked as the most important characteristic of the important characteristic of the internet related to clinical internet related to clinical informationby all types of md’s. informationby all types of md’s.

Family md’s said “too much Family md’s said “too much information to scan” – barrierinformation to scan” – barrier

Relevance considered very importantRelevance considered very important

ResultsResults

Because of the broad scope of family Because of the broad scope of family practice and exponential increase in practice and exponential increase in medical knowledge, mastery of medical knowledge, mastery of technology is a core skill.technology is a core skill.

Family md’s are driven by questions Family md’s are driven by questions regarding specific patients rather regarding specific patients rather than new research findings. than new research findings.

Specialist vs Family MDSpecialist vs Family MD Family Family

• Current best practices and clinical Current best practices and clinical guidelines most importantguidelines most important

SpecialistsSpecialists• In-depth knowledge in relatively In-depth knowledge in relatively

narrow areanarrow area• Access to cutting edge research and Access to cutting edge research and

journalsjournals• Contact with more limited population Contact with more limited population

of colleagues – many far awayof colleagues – many far away

Problems for allProblems for all

NavigationNavigation Lack of speedLack of speed Extensive amount of information to Extensive amount of information to

scanscan Lack of specificity for available Lack of specificity for available

informationinformation Obstacles greater for family md’sObstacles greater for family md’s

Handheld devices –PDA’sHandheld devices –PDA’s Family md’s more like to use theseFamily md’s more like to use these 80% of internists use PDA’s to access 80% of internists use PDA’s to access

drug informationdrug information Other uses:Other uses:

• textbookstextbooks• JournalsJournals• Medical calculatorsMedical calculators• Patient tracking programsPatient tracking programs• Billing and coding softwareBilling and coding software• Word processing Word processing • Internet access and more……Internet access and more……

PDA’sPDA’s

Drug prescribing most common Drug prescribing most common medical errormedical error

PDA’sPDA’s• save time in information retrieval, save time in information retrieval, • easily incorporated into their workflow easily incorporated into their workflow • Reduced rate of preventable adverse Reduced rate of preventable adverse

drug eventsdrug events

ResultsResults

Family md’s deal with broadest Family md’s deal with broadest clinical knowledge bases BUTclinical knowledge bases BUT• 2/3 of questions go unanswered2/3 of questions go unanswered• Only pursue urgent needs or high Only pursue urgent needs or high

probability of finding an answerprobability of finding an answer

MD’s have access to the internet and MD’s have access to the internet and are using itare using it• Consider it important Consider it important • Confident in their ability to use it(?)Confident in their ability to use it(?)

ResultsResults

They direct more attention to patient They direct more attention to patient care issues care issues

Overwhelmed by amount of clinical Overwhelmed by amount of clinical informationinformation

Lack of confidence that they will be Lack of confidence that they will be able to find an answerable to find an answer

PDA’s will grow in usePDA’s will grow in use

Other studiesOther studies

The most commonly reported The most commonly reported obstacle to the pursuit of an answer obstacle to the pursuit of an answer was the physician's doubt that an was the physician's doubt that an answer existed answer existed

The PDRThe PDR

What is the PDR?What is the PDR?

Adverse Drug EventsAdverse Drug Events

76.2% ADE’s are dose related76.2% ADE’s are dose relatedusing standard methods of careusing standard methods of care

Large number of serious ADEs even Large number of serious ADEs even when drugs are properly prescribed when drugs are properly prescribed and administeredand administered

1985 – 37,000 ADE reports to FDA 1985 – 37,000 ADE reports to FDA 71% “involved toxic reactions to 71% “involved toxic reactions to usual doses”usual doses”

Lazarou J, et al Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA 1998;279:1200-1205

Usual Dose of DrugUsual Dose of Drug

Doses recommended by Doses recommended by manufacturers package insertsmanufacturers package inserts

This is what is found in the PDRThis is what is found in the PDR Manufacturer-recommended doses of Manufacturer-recommended doses of

medications are usually selected medications are usually selected during phase 1during phase 1

After drug is introduced or general After drug is introduced or general use – and the package insert is use – and the package insert is written and codified in the PDR – written and codified in the PDR – THEN Phase 4 startsTHEN Phase 4 starts

Phase 4Phase 4

Risks become apparentRisks become apparent New uses for drugsNew uses for drugs Independent research reveals Independent research reveals

effectiveness of doses that differ effectiveness of doses that differ from the manufacturers from the manufacturers recommendationsrecommendations

This information does not get to the This information does not get to the physician.physician.

PDRPDR

82-90% md’s consider PDR single 82-90% md’s consider PDR single most useful referencemost useful reference(“publishing (“publishing company source”)company source”)

Average md consults 8 times a weekAverage md consults 8 times a week FREE - underwritten by the FREE - underwritten by the

pharmaceutical industrypharmaceutical industry

PDR informationPDR information

PDR info rarely updatedPDR info rarely updated PDR drug descriptions are not datedPDR drug descriptions are not dated There is no requirement for drug There is no requirement for drug

companies to update their package companies to update their package insertsinserts

No dosing adjustments for elderlyNo dosing adjustments for elderly Data regarding lower doses often Data regarding lower doses often

omitted (NSAIDS)omitted (NSAIDS)

Good DataGood Data

NSAIDS NSAIDS • Dose related ADEs from NSAIDS Dose related ADEs from NSAIDS

hae prompted more reports to the hae prompted more reports to the FDA than any other drug groupFDA than any other drug group

• Most NSAID ADE’s are dose relatedMost NSAID ADE’s are dose related• Annually, 8000-16,000 deaths and Annually, 8000-16,000 deaths and

70,000-107,000 hospitalizations 70,000-107,000 hospitalizations related to NSAID userelated to NSAID use

• Using lowest dose is criticalUsing lowest dose is critical

““The most common therapeutic The most common therapeutic intervention in medicine is writing a intervention in medicine is writing a prescription” Inadequate dosing prescription” Inadequate dosing information affects everyoneinformation affects everyone

NeedsNeeds

New constantly updated PDRNew constantly updated PDR Another drug reference with Another drug reference with

adequate informationadequate information Entirely new reference created from Entirely new reference created from

joint contributions of government, joint contributions of government, pharmaceutical industry, foundations pharmaceutical industry, foundations and phsyiciansand phsyicians

SMH Access statistics – 1 yearSMH Access statistics – 1 year

Mar 2004-Feb 2005, 4,554 articles Mar 2004-Feb 2005, 4,554 articles downloaded from NEJM.downloaded from NEJM.• 378 searches performed378 searches performed

ProQuest – 7,598 articles downloaded ProQuest – 7,598 articles downloaded in 12 monthsin 12 months

UpToDate – more than 300 time per UpToDate – more than 300 time per weekweek

JAMA – 12,000+ articles downloadedJAMA – 12,000+ articles downloaded 831 articles borrowed 831 articles borrowed 1,900+ requests to library 1,900+ requests to library

What does this mean?What does this mean?

Physicians need informationPhysicians need information Consistent, fast accessConsistent, fast access Valid resources to fit exact needsValid resources to fit exact needs Proper education in use of technologyProper education in use of technology TimeTime An administration that supports the An administration that supports the

financing of good informationfinancing of good information