Information To Guide Physician Practice: Overview
The information overload of physicians is getting worse, according to a U.S. Department of Health and Human Services (HHS) study conducted by the Lewin Group, which examined the information needs of physicians. The study synthesizes the literature on this topic, analyzes the opportunities and problems posed by electronic information sources, and contains the results of focus groups looking at these issues from the standpoint of practicing physicians. The effort has produced an electronic database of more than 200 articles researched for the study. The full report, "Information To Guide Physician Practice," with a 4-disk database, entitled the "Physician Information Literature Database," is available from the National Technical Information Service (NTIS), Springfield, VA 22161, telephone (703) 605-6000 or 800-553-6847. Order Accession Number PB97-500250, $50.00 U.S.
Summary
With the growing scope and complexity of medical information, physicians are finding it increasingly difficult to stay abreast of current medical knowledge. This growth in physician-targeted medical information is evident in the proliferation of subspecialty journals, the growing presence of clinical-economic studies, and the escalating marketing efforts of a range of actors. Policymakers and managed care providers have entered the fray, vying to affect physician practice with an expanding array of clinical guidelines, profiling, and utilization review.
The rapidly increasing availability of information has coincided with fundamental change in the structure and delivery of care. The many facets of health care integration include the growth of managed care, hospital mergers, formation of physician hospital organizations, and the expanding presence of corporate medicine. Access to medical information and dissemination of findings is central to the management of costs and clinical outcomes. Integration has also heightened the prospects for health data integration and the electronic medical record.
The medical community also stands poised for a major revolution in the way medical information is organized and disseminated. Electronic sources of information (e.g., medical outcomes software, proprietary access services, the Internet, and CD-ROM educational materials) are growing in number and popularity. Many physicians' offices are automating, in much the same way that hospitals and other medical institutions began to automate in the 1980s. Electronic information sources promise administrative simplification and ease of access to information, although, in many of their current forms, they also contribute to physicians' "information overload."
To understand this dynamic environment better, the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE), in collaboration with the Agency for Health Care Policy and Research (AHCPR), contracted with The Lewin Group to study the sources of physician information, the screens that physicians use to determine which information is most valuable, and the implementation of information in a practice environment. The study included three phases:
Literature Synthesis and Database Retrieval System
More than 200 articles from literature relating to the information environment faced by physicians were reviewed, major themes were synthesized, and an interactive database was created to allow researchers to access this literature easily.
Characterization of the Online Resources for Physicians
Because there was little literature characterizing online electronic sources of information (e.g., the Internet), a focused study of Online Medical Networked Information (OMNI) for physicians was completed.
Lessons from Physician Focus Groups
Given the rapidly changing environment, it was particularly important to test the findings in the field. Three focus groups were conducted: attending physicians in an academic medical center; a small rural practice; and a group of resident physicians.
Following are summaries of each of these areas, and some of the lessons that emerge from the study, highlighting examples from the focus groups.
Literature Synthesis and Retrieval System
The literature component of this study includes a targeted review and analysis of the role of information in shaping physician practice. The focus of the literature review is the practical use of information by physicians, rather than the theoretical underpinnings of information diffusion. The literature review includes recent scientific and non-scientific literature, as well as lay sources, including newspapers and newsletters.
The first phase in conducting the literature review was to create a structure within which the literature could be analyzed. An analytic framework for organizing the literature was developed, with three main categories:
Sources of information available to physicians: literature that describes or evaluates sources of medical information used by physicians in their professional practices. Sources of information include: journals; guidelines; marketing; Internet; informal information exchange; integrated information systems; decision support systems; continuing medical education; patient satisfaction; peer review/profiling; and utilization review.
Determinants of physician use of information: literature on factors affecting both the decision to use an information source and how the source is used. Determinants of information use include: physician age; physician training; physician specialty; physician practice location; legal environment; financial environment; administrative environment; source type; potential use; complexity/presentation; and voluntary/mandatory access.
Results of information use on physician behavior: literature that discusses the effects of information use on physician behavior and practice patterns. Results of information use are: physician change in service provision; physician change in guideline compliance; patient mortality; patient morbidity; patient quality of life; and patient behavior.
Electronic searching of major information collections and services was used to identify relevant articles for inclusion in the literature review. The search was limited to articles published from January 1, 1991, through November 1, 1995, since an annotated bibliography by the Agency for Health Care Policy and Research analyzed the literature prior to 1991 (Information Dissemination to Health Care Practitioners and Policymakers), AHCPR Pub. No. 92-0030. The search included information collections containing scientific and nonscientific literature, as well as collections containing lay sources, including newspapers and newsletters.
A graphical summary (39 KB) of the article selection process is provided.
Literature Review Findings
The literature on sources of information shows that physicians are receiving information from more varied sources than ever before. Journals continue to be an important and authoritative source of information, but suffer from speed of use and accessibility limitations. Electronic sources are often available more rapidly, but are currently not considered as dependable as journals. Although the field of medical informatics has advanced substantially over the last decade, the integration of patient information, clinical guidelines, expert medical systems, and administrative information is a critical concept still in its infancy.
The literature on determinants of information usage shows that physicians judge the information they review on the basis of a number of criteria. The imprimatur of a good journal is critical for credibility of new findings. Indeed, physician involvement in producing the source and the peer review process are often key ingredients for a source's credibility. Physicians are more likely to act on information if there is a monetary incentive involved, and to screen out information from questionable sources, highly complex data, and voluntary guidelines. The way a physician obtains and evaluates information is also influenced by a number of environmental factors, including specialty, age, and practice location.
The literature on use of information contains many examples of instances in which dissemination of clinical information (e.g., from clinical practice guidelines, integrated information systems, or physician education programs) has led to changes in physician practice. Integrated sources have great potential to help physicians cope with information overload, and have been shown to improve compliance with guidelines and reduce adverse events. However, such success stories are usually focused on specific examples, and there are few broader studies that cover multiple information interventions. In addition, the literature lacks systematic and representative studies of many common means of delivering information to physicians, such as journals, marketing, patient assessments, and information exchange.
The Database
To facilitate the literature analysis and the development of hypotheses for the focus groups, an interactive database was created, containing structured summaries and citation information of the reviewed articles. With an electronic database, focused searches can be conducted to explore the degree to which the literature addresses important topics related to the impact of information on physician practice.
The database was organized using the study framework described. The first screen of the database contains citation information, the study methodol
