SummaryMedical librarians at Vanderbilt University Medical Center's Eskind Biomedical Library, under the direction of Nunzia Bettinsoli Giuse, MD, MLS, developed the Clinical Informatics Consult Service, a rapid turnaround service to provide answers to medical queries from clinicians based on the latest evidence-based research. The goal of the program is to provide timely information to help improve clinician decisionmaking. Each librarian specializes in a particular clinical area and is assigned to a clinical team within that specialty. Hospital-based clinicians can ask questions during weekly patient rounds that are attended by the librarians, and inpatient- and outpatient-based clinicians can submit messages through an automated, secure messaging system. This system allows librarians to respond quickly to queries and to link their research findings to a patient's electronic medical record. Feedback from physicians suggests that the service has had a positive impact on clinician decisionmaking, and a randomized controlled trial found that more than 60 percent of questions that were not handled by the librarians were not pursued by physicians.Suggestive: The evidence consists of post-implementation surveys, focus groups, and anecdotal reports from users of the system.
Developing OrganizationsVanderbilt University Medical Center's Eskind Biomedical Library
Date First Implemented1996
Problem AddressedAlthough it is imperative that clinicians be aware of current research to provide high-quality care, many physicians do not have enough time to research medical questions, particularly in view of the growing volume of medical research that is available.
- No time for research, especially for complex questions: Although clinicians generally want to stay abreast of current research findings, the realities of day-to-day practice often prevent them from spending the time necessary to do so.1 Studies show that primary care physicians pursue only about 30 percent of their medical questions,2 while medical residents rarely seek answers to the many new clinical questions they encounter.3 Extensive time is needed to perform this type of research; experienced medical librarians spend an average of 2 hours researching each question forwarded by a provider, and they may spend 5 or more hours responding to complex questions that require extensive searching and filtering of the literature.1
- As a result, lack of evidence-based care and wasted effort: Numerous studies show significant gaps between the research evidence and the clinical care that is actually provided, underscoring the need for additional, systematic ways to integrate evidence into clinical practice.1 The failure to consult the research evidence not only represents a missed opportunity for education and the improvement of clinical practice, but also means that tremendous amounts of time, effort, creativity, and money are being spent on research that is not consistently being used in everyday practice.4
- Untapped potential and limited resources of medical libraries: Librarians can play a key role in advancing the use of evidence-based medicine.5 A study of Vanderbilt's Clinical Informatics Consult Service knowledge base found that many clinician-generated questions are complex, requiring representation of more than one viewpoint. These questions require comprehensive, critical appraisal of the medical literature, a need that can be filled by librarians trained in such techniques. However, many hospital and academic medical center libraries have limited time and resources to assist in literature searches and critical appraisals of the literature on behalf of providers, particularly on complex or unusual conditions. In addition, even when highly skilled, resource-rich librarians are available, they are seldom integrated into care teams or easily accessible to clinicians; for example, few medical centers enable librarians to accompany clinicians on rounds, although the interactions and discussions that occur during these rounds can be helpful.
Description of the Innovative ActivityVanderbilt University Medical Center's Eskind Biomedical Library developed the Clinical Informatics Consult Service to deploy specialty-specific medical librarians to locate and evaluate medical information in response to queries from residents and clinicians in Vanderbilt's inpatient units and outpatient clinics. In the hospital setting, the librarian accompanies clinical teams on rounds to capture medical questions. In addition, inpatient and outpatient providers can contact their designated librarian via secure messaging in the electronic medical record (EMR) about clinical questions that arise during everyday practice. Librarians relay their findings through a special e-mail messaging service to providers, and they can also provide a link to the findings in the patient's chart within the EMR. Highlights of the program are described below:
- Specialty-specific librarians: Each Clinical Informatics Consult Service librarian specializes in a particular clinical area, focusing on the examination of diverse sources of evidence and the interpretation and synthesis of medical articles within that specialty. Two librarians specialize in internal medicine, working with teams in the inpatient and outpatient settings; in addition, the following specialties have a dedicated librarian: surgery/trauma, emergency medicine, neonatal intensive care, breast cancer/tumors, diabetes, pulmonary medicine, and neurology. The Clinical Research Center has a dedicated librarian as well.
- Submission of queries to the librarians: Clinicians have two vehicles through which they can submit queries, as described below:
- During medical team inpatient rounds: In the inpatient setting, librarians accompany their medical teams on rounds roughly once a week, making note of research-based questions from any member of the team. When questions arise, the librarian helps identify and frame those that can be researched; most questions relate to the description, diagnosis, or treatment of specific diseases.
- Through secure messaging service: After a previous attempt to integrate librarians in person into outpatient settings, the library began utilizing a secure messaging system through the EMR (known as StarPanel) that allows providers and residents in the hospital and outpatient clinics to send questions to medical librarians. Each outpatient clinical area has one librarian designated as its primary liaison, with additional members of the library team substituting as needed. Librarians adhere to the same privacy and confidentiality guidelines as clinicians.
- Librarian-directed research and response: The librarian thoroughly searches library resources and selects the most relevant and high-quality evidentiary articles to answer every inquiry received. Instead of simply providing references to providers, Clinical Informatics Consult Service librarians filter the research by reading, highlighting, and summarizing the articles as they relate to the clinical case at hand. The librarians are careful to point out conflicting data and opinions when a clear consensus is lacking. Answers are sent to the clinician through the StarPanel messaging system. In addition to providing answers to research questions, Vanderbilt librarians also teach residents the skills to research biomedical information on their own.
- Rapid turnaround, with response time dictated by clinical need: If an answer is needed immediately owing to a medical crisis, the librarian immediately researches the question, providing an answer within 2 to 3 hours. Less urgent questions are answered in 2 to 3 days, whereas responses to general, nonurgent questions may take up to 1 week.
- Link to research findings embedded in patient's EMR: A patient's chart and EMR identification number are made available as part of the query. The librarians can consult relevant details of the patient's record as needed to tailor the literature search and respond via the EMR's messaging feature. Physicians also can store a link to the librarian's findings within the patient's chart in the EMR through the StarPanel system. Other physicians can also access this link and benefit from the information, and the lead physician can forward the link to the entire medical team if so desired.
- Updates to answers: The librarian who answers a provider's question becomes the "owner" of the question and is responsible for updating the answer as needed. To accomplish this task, the librarian assigns each question to a record; the system creates an automatic link from the record to the search strategy originally used by the librarian, who then updates the search with information added since the original search. The librarian also regularly reviews the Clinical Informatics Consult Service database to assess whether new articles should be added to each record. Information provided in October 2012 indicates that clinicians can also request that librarians update certain answers if a topic is being revisited for further debate.
- New activities: Information provided in October 2012 indicates that several new activities have developed out of the original Clinical Informatics Consult Service work; these new activities include the following:
- Evidence-based practice research: Vanderbilt University Medical Center is an AHRQ Evidence-based Practice Center (EPC). Several librarians trained in skills related to the Consult Service participate in systematic review work related to EPC projects; librarians serve as co-investigators on these projects by participating in all project phases, including (but not limited to) executing and refining the literature searches related to EPC projects.
- Evidence base for clinical informatics applications: Librarians work with clinical teams to review and update the evidence that forms the basis for provider computerized order entry, order sets, and clinical decision support tools used in inpatient care.
- Research on patient health literacy and learning styles: Librarians are leading research efforts related to patient health literacy and learning styles in order to enhance the medical information provided to patients. Following a background research effort, randomized controlled trials related to hypertension and diabetes have shown the merit of personalized approaches.
- Participation in the Clinical and Translational Science Award (CTSA) project: Library information scientists, including librarians and professionals with advanced degrees in other areas such as pharmacogenetics, are participating in the National Institutes of Health's CTSA project, for which Vanderbilt University Medical Center is a consortium leader. This team researches the pharmacogenetic evidence to be put into the hospital's EMR system so that optimal medical therapies can be selected based on patients' genetic profiles. The team is also working to translate genetic and drug information into user-friendly language to be added to patients' personal health record.
- Diagnostic management teams: Library information scientists collaborate with expert clinicians in multidisciplinary diagnostic management teams that address the interpretation and utilization of diagnostic tests; librarians research and provide the evidence to support these efforts.
Context of the InnovationVanderbilt University Medical Center in Nashville, TN, is a comprehensive health care facility dedicated to patient care, research, and biomedical education. It is home to a variety of outpatient clinics and hospitals, including the 600-bed Vanderbilt University Hospital, which is the site of the region's only Level I Trauma Center and the region's only Level IV neonatal intensive care unit. The center also hosts the Monroe Carell, Jr. Children's Hospital at Vanderbilt, the Vanderbilt Clinic and its 100 ambulatory specialty practices affiliated with the Vanderbilt Medical Group, the Vanderbilt-Ingram Cancer Center, the Nashville Veterans Administration Medical Center, and the Vanderbilt University Schools of Medicine and Nursing.
Vanderbilt's Eskind Biomedical Library, which serves the entire medical center, developed a service providing clinical information, called the Clinical Informatics Consult Service, as a local strategy to provide clinicians with the latest evidence to support patient care. The initiative was spearheaded by the library's director, also a physician, who wanted to provide clinicians with the latest, highest quality, and most relevant research to support effective clinical decisionmaking and evidence-based practice.
Although the service initially focused primarily on librarian consultations with clinicians during inpatient morning rounds, library staff also recognized a need to adapt this model to provide service to the medical center's outpatient clinics, where attending physicians and house staff care for patients in individual examination rooms rather than through the group "bedside rounds" of the inpatient setting.
In late 2003, the library began using the medical center's EMR system, StarPanel, as an entry point into the outpatient arena.
ResultsAlthough it is difficult to measure the direct impact of the program on clinical care, physicians who used the service and responded to surveys indicated that the information provided was highly relevant to their clinical practice, and most reported sharing the information with colleagues.
Suggestive: The evidence consists of post-implementation surveys, focus groups, and anecdotal reports from users of the system.
- High satisfaction and positive impact on decisionmaking: One study, which used a focus group and survey, explored the use of the service by 137 primary care physicians. Forty-eight (35 percent) of those surveyed responded. The 19 who had used the service ranked the information as "highly relevant to their clinical practice," and 15 reported sharing the information with colleagues.6 In another study, researchers examined the impact of the Clinical Informatics Consult Service on clinicians' treatment choices by comparing the choices of doctors who used the service with those of doctors who did not have access to the service. During a 19-month study period, 226 Clinical Informatics consults were made; 65 percent of the clinicians who initiated these consults requested updates on current research and were satisfied with the results. The information positively influenced these physicians' intention to treat, compared with the decisions of those without access to the service; the service's information primarily affected the use of a new or different treatment.7 Surveys of providers also revealed that they viewed the monthly newsletter as highly effective.
- Positive feedback from users of a similar program in other settings: In a survey of more than 5,000 physicians in Wales who used an online research database, which provided information similar to that offered by the medical librarians at Vanderbilt, 88 percent believed that it had the potential to improve patient care; 41 percent reported that the system directly improved care for their own patients.8
Planning and Development ProcessKey steps in the planning and development process include the following:
- Obtaining clinician buy-in: Clinicians at Vanderbilt varied in their willingness and interest in working with medical librarians. To help convince clinicians of the value of the service, the librarian team met with individual clinical directors to educate them about what the research service offers and to show them how it could effectively meet the needs of the clinicians within their departments.
- Supporting librarians in developing specialized expertise: Vanderbilt assigns librarians to clinical fields they are interested in, and they identify the publications and resources most applicable to that specialty. Librarians have also been encouraged to sit in on medical school classes and other workshops to broaden their knowledge within their chosen specialty.
- Creating the technology: Vanderbilt's information technology staff worked with program leaders to use the dedicated messaging system, StarPanel, that allows clinicians and librarians to communicate with each other and to access and attach information within a patient's EMR as needed so that research results can be linked to patient charts.
- Providing monthly training: Clinical Informatics Consult Service librarians participate in monthly training conferences that focus on how to perform database searches, evaluate study design, weigh evidence from articles, and summarize and present information effectively.
- Expanding the program: Although the service initially focused on librarian consultations with clinicians during inpatient morning rounds, library staff recognized the need to expand the service to offsite clinicians. Information provided in October 2012 indicates that the program has expanded to include librarian participation in a number of additional activities.
- Maintaining high quality: The librarian-created information packets are reviewed and critiqued by senior staff on a quarterly basis to provide ongoing quality assurance for the program staff and identify areas for additional growth among team members.
Resources Used and Skills Needed
- Staffing: Vanderbilt employs 12 librarians in the consultation service, with 8 assigned to specific care teams and 4 serving as generalists who provide additional coverage and backup. The number of questions posed by providers varies, ranging from 1 or 2 to up to 14 per week. The library director restructured the library's reference desk, allocating staff to handle providers' questions and accompany them on rounds. All librarians have completed undergraduate degrees (in a variety of fields), and all have a master's degree in library science. Regardless of their background, librarians must have an interest in medicine, be committed to continual learning, work well in teams, and have strong written and oral communication skills that allow them to succinctly summarize complex research results. Information provided in October 2012 indicates that, as the team's responsibilities have expanded to new projects, information specialists with doctoral degrees in neuroscience, biochemistry, and other clinical fields have been added to the library team.
- Costs: Each librarian has a starting salary of roughly $44,000, excluding benefits.
- Technology: The costs of StarPanel and other informatics applications are part of the medical center's information technology budget.
Funding SourcesVanderbilt University Medical Center's Eskind Biomedical Library
The Clinical Informatics Consult Service is funded internally by Vanderbilt as part of the library's budget.
Tools and Other ResourcesEskind Biomedical Library's Evidence-Based Services. Available at: http://www.mc.vanderbilt.edu/km/ebm/.
There are also some sample questions at this Vanderbilt site: http://www.mc.vanderbilt.edu/vumcdiglib/geriatrics/info/index.html and at this blog: http://jmlacasestudies.blogspot.com.
Getting Started with This Innovation
- Use librarians to encourage physician buy-in: Librarians can serve as effective program advocates, meeting with clinicians to explain the potential benefits of the service. Getting the support of clinical directors is especially important to the program's success.
- Allow librarians to choose specialties: Each librarian should work with a specialty with which he or she feels a close connection and should expand his or her knowledge base by auditing classes, reading, and attending conferences.
- Upgrade research capabilities: Make sure the library has access to all the available clinical research literature and major search databases.
- Create messaging service to link outpatient clinicians: If appropriate, create an e-mail messaging service so that both inpatient and outpatient clinicians can pose questions at any time.
- Consider links to patient EMR: If an EMR is used, consider making the patient records available to searchers to help pinpoint and clarify questions, and consider making research results available within the patient's record for easy access by clinicians.
- Integrate information professionals into clinical and project teams: Librarians and other information professionals should be fully integrated into project teams in order to ensure that they understand information needs, maximize their contribution, and foster the development of collegial relationships with clinicians. For example, librarians should be included in project meetings and should be incorporated into medical rounds. By accompanying clinicians on medical rounds, librarians learn about the information and treatment challenges faced by providers and get a good sense for the degree of urgency for the specific questions being asked. This knowledge allows librarians to conduct more refined, timely searches that better address the specific question(s) being asked, which is especially helpful for patients with complex, co-occurring conditions.
Sustaining This Innovation
- Continually promote availability of service: It is easy for busy clinicians and residents to forget about the medical library service unless they are continually reminded of its availability. At Vanderbilt, the librarian makes frequent visits to the clinics to remind clinicians about the service.
- Use librarians to support residents: Librarians can be a valuable source of support for residents. At Vanderbilt, the librarians teach residents how to conduct their own searches and help them in preparing their presentations during morning rounds.
Contact the InnovatorNunzia Bettinsoli Giuse, MD, MLS
Library Director and Professor of Biomedical Informatics and Medicine
Rebecca Jerome, MLIS, MPH
Program Director and Assistant Professor, Department of Biomedical Informatics
Taneya Y Koonce, MSLS, MPH
Associate Director for Research
Annette Williams, MLS
Eskind Biomedical Library
Vanderbilt University Medical Center
2209 Garland Avenue
Nashville, TN 37232-8340
Fax: (615) 936-1384
Innovator DisclosuresDr. Bettinsoli, Ms. Jerome, Ms. Koonce, and Ms. Williams have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesGiuse NB, Koonce TY, Storrow AB, et al. Using health literacy and learning style preferences to optimize the delivery of health information. J Health Commun. 2012;17 Suppl 3:122-40. [Pubmed] Available at: http://www.tandfonline.com/doi/abs/10.1080/10810730.2012.712610. (Added October 2012.)
Snyder B. Meeting explores PREDICT’s vast potential. The Reporter: Vanderbilt University Medical Center’s Weekly Newspaper. 28 June 2012. Available at: http://www.mc.vanderbilt.edu/reporter/index.html?ID=12942. (Added October 2012.)
Snyder B. ’Clotting team’ aids diagnosis, decision making. The Reporter: Vanderbilt University Medical Center’s Weekly Newspaper. 5 August 2010. Available at: http://www.mc.vanderbilt.edu/reporter/index.html?ID=9211. (Added October 2012.)
Jerome R, Giuse N, Rosenbloom S, et al. Exploring clinician adoption of a novel evidence request feature in an electronic medical record system. J Med Libr Assoc. 2008;96(1):34-41. [PubMed]. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2212326/.
Mulvaney S, Bickman L, Giuse N, et al. A randomized effectiveness trial of a clinical informatics consult service: impact on evidence-based decision-making and knowledge implementation. J Am Med Inform Assoc. 2008;15(2):203-11. [PubMed]. Available at: http://jamia.bmj.com/content/15/2/203.abstract?15/2/203.
Jerome R, Miller R. Expert synthesis of the literature to support critical care decision making. J Med Libr Assoc. 2006;94(4):376-81. [PubMed]
Westbrook J, Gosling A, Coiera E. Do clinicians use online evidence to support patient care? A study of 55,000 clinicians. J Am Med Inform Assoc. 2004;11(2):113-20. [PubMed] Available at: http://jamia.bmj.com/content/11/2/113.abstract?sid=7ad221d3-9ac3-47ae-b714-5a482c0e05cd.
Giuse N, Koonce T, Jerome R, et al. Evolution of a mature clinical informationist model. J Am Med Inform Assoc. 2005;12(3):249-55. [PubMed]
Gorman PM, Helfand M. Information seeking in primary care: how physicians choose which clinical questions to pursue and which to leave unanswered. Med Decis Making. 1995;15(2):113-9. [PubMed]
Green ML, Ciampi MA, Ellis PJ. Residents' medical information needs in clinic: are they being met? Am J Med. 2000 Aug 15;109(3):218-23. [PubMed]
Mulvaney S, Bickman L, Giuse NB, et al. A randomized effectiveness trial of a clinical informatics consult service: impact on evidence-based decision-making and knowledge implementation. J Am Med Inform Assoc. 2008;15(2):203-11. [PubMed]
Available at: http://jamia.bmj.com/content/15/2/203.abstract?
Westbrook JI, Gosling AS, Coiera E. Do clinicians use online evidence to support patient care? A study of 55,000 clinicians. J Am Med Inform Assoc. 2004;11(2):113-20. [PubMed]
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Original publication: August 18, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: January 15, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: November 09, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.