Distribution of a primary care office information system.

Distribution of a Primary Care Office Information System G. Octo Barnett, MD1,2, Edward P. Hoffer, MD1,2 , Elizabeth Schneider, MLS 3 , Mary Morgan, BS1 , Cynthia Maciel Knowles, BA1 , Elina Levin, BA1 , Aimee Lee, BS1 Massachusetts General Hospital Laboratory of Computer Science 1 , Harvard Medical School Department of Medicine 2 and Treadwell Library 3 , Boston, Massachusetts Primary Care Office InSite (PCOI) is a Web-based intranet application that provides ready access to a collection of information useful in primary care. The PCOI Web site was developed by, and is widely used within, the Massachusetts General Hospital (MGH) and its affiliated community practices. Over 1600 users logged 60,000 separate sessions in the past year. The site contains clinical practice guidelines, patient educational material, drug prescription and cost information and referral information, all designed for use during routine patient care activity. This paper discusses the problems encountered and the lessons learned during an ongoing experiment to disseminate PCOI via the Internet to four distant and very different ambulatory care sites. None of these sites (a rural community hospital, a city-wide health care network, an inner -city general hospital, and an Indian Health Service hospital have the resources to develop such an application internally. INTRODUCTION One of the recommendations from the Institute of Medicine (IOM) report on improving the delivery of medical care was to utilize information technology in daily practice to increase the use of scientifically valid decision-making.1 Studies have repeatedly shown that the information needs of primary care physicians (PCPs) are not being met2, 3 . While there is a wealth of information available on the Internet, this information is not readily available and not optimally organized for use during daily patient care. The information needs of primary care physicians and their information-seeking behaviors have been widely studied. The findings have been remarkably similar among clinicians at different levels of training and practice settings and across different cultures. An 4 excellent review by Smith summarized a group of studies showing that the questions are often complex and multidimensional, and that doctors are most likely to seek answers to their questions from other doctors. Most of the questions generated by doctors can be answered, using electronic sources, but this is time consuming and expensive—and demands information skills that many doctors lack. The typical primary care patient visit lasts 10-15 minutes. During that brief time, the PCP must review the patient’s chart, take a history, perform the necessary physical exam, discuss his/her findings, write prescriptions, fill out a billing/encounter form and write a note in the chart. At the same time, he or she must try to fulfill the needs of the patient for emotional support and understanding. It is not surprising that PCPs rarely search external sources for information. Even though many would agree that it is not optimal, mo st physicians rely on their personal knowledge and memory rather than pub5 lished guidelines or the medical literature . As McKibbon et al note, “Because of other demands on their time, clinicians preferred to take less than two 6 minutes per question to find answers .” Many of the clinical questions that go unanswered during daily practice can be answered from the literature. In an Oregon study, medical librarians were asked to use only online resources to answer 60 PCP-generated questions. Time or cost res trictions were not applied to the searches. These “gold standard” searches averaged 43 minutes in length and $27.37 in cost. The clinicians judged the answers relevant in 56% of cases, and said that the information provided a "clear answer" to 46% of their 7 questions . The value of the trained searcher is not under question; however, the time and cost involved makes this approach impractical. There has been increasing attention to developing guidelines that promote evidence-based medicine, but less attention to mechanisms to transfer evidence into clinical practice and to keep up with the ever-increasing amount of clinical trial data. The reality is that it is nearly impossible for any human-based information service to provide cost-efficient, timely information under the two-minute deadline needed to satisfy a PCP. Shifting the work of answering questions that arise in daily practice to a computer-based information resource may provide the Just-in-Time 8 information desired at the point of care. BACKGROUND In 1996, the Massachusetts General Hospital (MGH) began a number of operation improvement AMIA 2003 Symposium Proceedings − Page 61 initiatives to identify and implement changes that would improve patient care, increase patient satisfaction, and promote cost-effective decisionmaking. One initiative of the General Medicine Unit was the development of evidence-based clinical guidelines focused on clinical relevance and potential to improve medical care efficiency and effectiveness. The guidelines, developed by a working group of the MGH adult medicine primary care practices, were not meant to represent hard and fast rules; clinical judgment is required in applying these guidelines to any individual patient. The philosophy of the work group was that time and resources are limited in primary care practice; therefore, selection and prioritization of recommended care guidelines should be based on the strength of direct evidence of benefit from clinical research. Individual guidelines were sent to MGH primary care and specialty content experts for review and comment; however, no clinicians outside the work group were asked to approve or endorse these guidelines. The work group considers it to be an ongoing responsibility to review and revise the existing guidelines as new evidence becomes available. The guidelines were initially distributed to MGH adult primary care clinicians in hard-copy form but we soon realized that the size of the notebook would inhibit physicians from accessing this material in their routine patient care practice and that it would be difficult to distribute new or revised material in a timely fashion. Therefore we shifted the distribution from a printed binder to the MGH intranet taking advantage of Web technology to facilitate indexed searching, ease of navigation, and linking of related patient instruction materials to clinical guidelines to better respond to the point-of-care physician information needs. There are three different approaches to provide Web-based clinical information: providing pointers to information resources available over the Internet; providing electronic versions of commercially available standard medical reference sources; and creating a local information repository which combines focused, patient-centered knowledge and patient-specific recommendations and resources that facilitate the informat (...truncated)