DOI: 10.1111/hir.12048

Review Article Online strategies to facilitate health-related knowledge transfer: a systematic search and review Katie Mairs, Heather McNeil, Jordache McLeod, Jeanette C. Prorok & Paul Stolee School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada

Abstract Background: Health interventions and practices often lag behind the available research, and the need for timely translation of new health knowledge into practice is becoming increasingly important. Objective: The objective of this study was to conduct a systematic search and review of the literature on online knowledge translation techniques that foster the interaction between various stakeholders and assist in the sharing of ideas and knowledge within the health field. Methods: The search strategy included all published literature in the English language since January 2003 and used the MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE and Inspec databases. Results: The results of the review indicate that online strategies are diverse, yet all are applicable in facilitating online health-related knowledge translation. The method of knowledge sharing ranged from use of wikis, discussion forums, blogs, and social media to data/knowledge management tools, virtual communities of practice and conferencing technology – all of which can encourage online health communication and knowledge translation. Conclusions: Online technologies are a key facilitator of health-related knowledge translation. This review of online strategies to facilitate health-related knowledge translation can inform the development and improvement of future strategies to expedite the translation of research to practice. Keywords: Health services research, Internet, knowledge management, knowledge transfer, review and systematic search

Key Messages

• • • • •

Online strategies for health-related knowledge translation can act as vehicles to link researchers, practitioners, policymakers and consumers, thus facilitating the timely and relevant exchange of information, including where gaps in knowledge exist. Information and communication technologies are a pragmatic and timely means to selectively transfer valuable research to policy makers, healthcare providers, the public and other stakeholders. Information and communication technologies, particularly the Internet, have also produced knowledge translation challenges including access to and user knowledge of online technologies. Through online technologies, it is possible for stakeholders to share knowledge regardless of geographical constraints, thus encouraging the advancement of knowledge in health and subsequent translation to practice. Virtual communities of practice are an effective and pragmatic way for health professionals, the general public and other key stakeholders to interact and share knowledge.

Correspondence: Paul Stolee, School of Public Health and Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, ON, Canada N2L 3G1. E-mail: [email protected]

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Introduction Knowledge transfer and translation (KT) have gained considerable recognition within the healthcare field. The Canadian Institutes of Health Research, a prominent Canadian funding agency and proponent of KT, has defined this important aspect of research as ‘a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to improve the health of [the population], provide more effective health services and products and strengthen the healthcare system.’1 This definition indicates that knowledge translation is a process that bridges the gap between the creation of knowledge and the application of this knowledge into practice. Knowledge translation strategies facilitate collaboration and exchange among researchers, healthcare practitioners, policy makers and the general public, ensuring the relevance and applicability of the research. Without methods for the successful translation of new knowledge into practice, healthcare practices and policies can remain outdated, and in some cases, even harmful. A growing body of literature demonstrates this detrimental lag in translating research into healthcare practice.2 For example, a 2006 RAND report examined quality indicators within a population of randomly selected patients from 12 metropolitan areas and found that 45% of patients were not receiving the care recommended by the research.3 These findings illustrate the need for efficient and diverse health-related KT strategies. Information and communication technologies are a pragmatic and timely means to selectively transfer valuable research to policy makers, healthcare providers, the public and other stakeholders.4 However, information and communication technologies, and in particular the Internet, have also produced KT challenges. For example, information overload has been reported for both clinicians5 and the general public6 when searching for health-related information online. This suggests that the proliferation of knowledge may require both time and proficiency on behalf of the user to sift through the available information.7 As a result, there is a growing need for knowledge exchange strategies that can share current, reliable, easily accessible information pertaining to specific health domains. These strategies can provide a

vehicle to link various stakeholders such as health consumers, health providers and decision makers. Our interest in this area emerged from our work with the Canadian Dementia Knowledge Translation Network (www.lifeandminds.ca, funded by the Canadian Institutes of Health Research) which involved online KT strategies (e.g. www.dementia knowledgebroker.ca). The purpose of this study was to systematically search and review the current literature regarding various online healthrelated KT techniques that foster interaction among various stakeholders and assist in the sharing and exchange of information, ideas and resources within the health field. Methods Our search used a systematic search and review method, as defined in the typology of reviews provided by Grant and Booth.8 Criteria for article selection For inclusion in this review, articles must have been published in the English language since January 2003. This time frame was selected as it reflected the approximate beginning of a surge in online techniques for KT. Additional inclusion and exclusion criteria were formulated using a Population, Intervention, Method, Outcome (PIMO) structure. PIMO was adapted from the Population, Intervention, Comparison, Outcome (PICO) framework9 that has been widely used to guide the development of comprehensive, well formulated, evidencebased clinical questions, and to help facilitate the planning process for health research. The authors felt that the term ‘Method’ more appropriately captured the types of KT strategies and tools in this heavily technology-based research, rather than the term ‘Comparison’ which is better suited to medical research where two groups receiving different interventions are compared. Figure 1 outlines the inclusion and exclusion criteria applied to the retrieved articles. Search methodology A search methodology was developed with the assistance of a health sciences librarian. A comprehensive

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MEDLINE database (N = 3128)

CINAHL database (N = 3282)

EMBASE database (N = 884)

INSPEC database (N = 1198)

Articles for review (N = 8492)

Results cross-referenced for removal of duplicates. Articles for review (N = 6502) Inclusion and exclusion criteria applied to the title and abstract of citations. Inclusion criteria: • Population o Researchers; Practitioners; Policymakers; Patients; Caregivers; Communities of practice • Intervention o Internet websites; Online support groups/Self-help groups; Webbased patient portals; Disease management • Method o Any method used in Internet websites • Outcome o Online interactions/collaboration

Exclusion criteria: • Population o (Passive) students; customers; children • Intervention o Face-to-face meetings; Internal organizational websites; Online learning; Professional knowledge exchange (pricing); E-maintenance; Linking to network. • Outcome o Dissemination only

Articles for text review (N = 152) Inclusion and exclusion criteria applied to text of remaining citations

Articles accepted (N = 45) Review of reference lists (N = 0) Total articles accepted (N = 45)

Figure 1 Search methodology flow diagram

search was conducted of the MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE and Inspec databases. MEDLINE was determined to be a pertinent database, as it spans a range of health science, life science, social science and physical science journals. CINAHL is the most comprehensive resource for nursing and allied health literature and was included as KT has been identified as a topic of increasing popularity in the nursing literature. EMBASE was selected as it has a broad biomedical scope. Inspec was included as it is a major indexing database of scientific and technical literature. Figure 1 outlines the search strategy and the number of articles retrieved from each database. The final search strategy includes the following: MEDLINE database: 1. exp diffusion of innovation/or knowledge management/or information dissemination/ 2. (knowledge adj2 (exchang$ or transfer$ or translat$ or diffus$ or disseminat$ or broker$ or

management or mobiliz$ or mobilis$ or distribut$ or utili$)).tw. 3. exp Internet/ 4. (Internet or online or on-line or web-based or web based or website or web site or blog$ or social networking or social media or facebook).tw. 5. 3 or 4 6. (research adj2 (practice or action or implement$ or translat$ or disseminat$ or utili$)).tw. 7. 1 or 2 or 6 8. 5 and 7 9. limit 8 to (english language and yr=“2003 Current”) CINAHL database: S1 (MH “Internet+”) OR (MH “blogs”) S2 TI (Internet or online or on-line or web-based or “web based” or website* or “web site*” or blog* or “social networking” or “social media” or facebook) OR AB (Internet or online or on-line or web-based or “web based” or website* or “web

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site*” or blog* or “social networking” or “social media” or facebook) S3 S1 or S2 S4 (MH “Theory-Practice Relationship+”) OR (MH “Professional Practice, Evidence-Based+”) OR (MH “diffusion of innovation”) AND (MH “action research”) S5 TI (knowledge N2 (exchang* or transfer* or translat* or diffus* or disseminat* or broker* or management or mobiliz* or mobilis* or distribut* or utili*)) OR AB (knowledge N2 (exchang* or transfer* or translat* or diffus* or disseminat* or broker* or management or mobiliz* or mobilis* or distribut* or utili*)) OR TI (research N2 (practice or action or implement* or translat* or disseminat* or utili*)) OR AB (research N2 (practice or action or implement* or translat* or disseminat* or utili*)) S6 S4 or S5 S7 S6 AND S3 (Limit to English, peer reviewed, Exclude MEDLINE) EMBASE database: 1. (knowledge adj2 (exchang$ or transfer$ or translat$ or diffus$ or disseminat$ or broker$ or management or mobiliz$ or mobilis$ or distribut$ or utili$)).tw. 2. (research adj2 (practice or action or implement$ or translat$ or disseminat$ or utili$)).tw. 3. information dissemination/or translational research/or participatory research/ 4. 1 or 2 or 3 5. Internet/ 6. (Internet or online or on-line or web-based or web based or website or web site or blog$ or social network$ or social media or facebook).tw. 7. 5 or 6 8. 4 and 7 9. limit 8 to (english language and yr=“2003 Current”) Inspec database: (((((((((((($knowledge NEAR/1 $mobilisation) WN KY) OR (($knowledge NEAR/1 $distribution) WN KY)) OR (($knowledge NEAR/1 $distribute) WN KY)) OR (($knowledge NEAR/1 $utilize) WN KY)) OR (($knowledge NEAR/1 $utilization) WN KY)) OR (($knowledge NEAR/1 $utilise) WN KY)) OR (($knowledge NEAR/1 $utilisation) WN KY)) AND (1980–2013 WN YR)) OR

((((((((($knowledge NEAR/1 $mobilisation) WN KY) AND (($knowledge NEAR/1 $distribution) WN KY)) AND (($knowledge NEAR/1 $distribute) WN KY)) AND (($knowledge NEAR/ 1 $utilize) WN KY)) AND (($knowledge NEAR/1 $utilization) WN KY)) AND (($knowledge NEAR/1 $utilise) WN KY)) AND (($knowledge NEAR/1 $utilisation) WN KY)) AND (1980–2013 WN YR)) OR (((((((((((($research NEAR/1 $practice) WN KY) OR (($research NEAR/1 $action) WN KY)) OR (($research NEAR/1 $implement) WN KY)) OR (($research NEAR/1 $translating) WN KY)) OR (($research NEAR/1 $translate) WN KY)) OR (($research NEAR/1 $translation) WN KY)) OR (($research NEAR/1 $dissemination) WN KY)) OR (($research NEAR/ 1 $disseminate) WN KY)) OR (($research NEAR/ 1 $utilize) WN KY)) OR (($research NEAR/1 $utilization) WN KY)) AND (1980–2013 WN YR)))) AND ((($Internet OR $online OR $on-line OR $web-based OR {web based} OR website* OR {web site*} OR blog* OR {social networking} OR {social media} OR $facebook) WN KY) AND (1980–2013 WN YR))) +{english} WN LA +({ja} OR {ca}) WN DT +(2012 OR 2011 OR 2010 OR 2009 OR 2008 OR 2007 OR 2006 OR 2005 OR 2004 OR 2003) WN YR (records were limited to 2003+, English, journal article or conference article) The reference lists of the total accepted articles (n = 45) were hand-searched to ensure that pertinent and eligible articles were not missed. Literature review articles that were relevant to the topic were initially included for full text review (n = 5), but were subsequently excluded, as it was difficult to apply the PIMO settings given that these articles discussed multiple studies. However, to ensure that additional relevant articles were not missed, the reference lists of these articles were also hand searched. Data collection and analysis All retrieved articles were independently reviewed by two researchers. Any disagreements between the two reviewers regarding the inclusion or exclusion of articles were resolved through discussion and consensus. The database search results were initially crossreferenced for the removal of duplicate articles.

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Once duplicate articles were removed, the inclusion and exclusion criteria were applied to the title and abstract of the retrieved sample of articles. The remaining accepted articles then underwent a subsequent full-text review. The final sample of accepted articles was then summarised into a premade data abstraction template, created by the authors, in order to assist with interpretation of the results. The template included the following categories: study design, country, target audience/population, health topic or context KT strategy and outputs/outcomes (Fig. 1). Results The aforementioned search strategy yielded a total of 8492 results between the four databases. Once duplicates were removed, 6502 articles underwent title and abstract review using the specified inclusion and exclusion criteria, resulting in a total of 152 articles; the inclusion and exclusion criteria were then applied to the full text, resulting in 45 remaining citations. Hand-searching of the reference lists of the retrieved accepted articles (n = 45) and the initially accepted literature review articles (n = 5) did not result in the inclusion of any additional articles, maintaining a final sample of 45 articles. Table 1 provides a detailed summary of the final sample of accepted articles derived from the aforementioned data abstraction template. The final sample of articles10–54 represented applications of online health-related KT strategies in six countries, with the majority of articles originating from the United States. The KT strategies utilised were quite broad, with some studies using more than one type of approach. Knowledge management strategies [e.g. online listservs and virtual journal clubs (VJC)]11,12,16,19–22,26,29,36,37,42,46,50, 52,53 were the most commonly cited approach for translating health-related knowledge to practice (n = 16), followed next by discussion forums13,15,20,24,26,33,39,44,47,51,53,54 (n = 12), virtual communities of practice (VCoP)14,17,18,25,30,31,34,39, 40,52 (n = 10), blogs23,28,42–44,50 (n = 6), wikis23,35, 38,39,45 (n = 5), Facebook27,42,43 (n = 3), conferencing technology32,41,42,48 (n = 4) and Twitter2,43 (n = 2). Eighteen (40%) of the articles were classified as qualitative10,14,15,17,18,26–29,31–33,35,39,41,42,45,47 generally

utilising interviews and focus groups with users to learn about the benefits, limitations, and preferences of a given population towards a specific KT strategy, and employing content analysis to analyse the results. Sixteen (35%) of the articles reviewed were classified as primarily descriptive.11,12,13,19,23,24,25,30,34,37,38,44,46,50,51,52 The majority of these articles described specific examples of online KT strategies that had been implemented; however, few provided analytical evidence regarding the strategies efficacy. Six (13%) of the articles were classified as quantitative21,36,43,49,53,54 and five as mixed methods16,20,22,40,48 (11%). Mixed methods studies often employed the use of interviews or observations as well as questionnaires, while the quantitative studies primarily utilised a questionnaire to obtain feedback on a given online KT strategy. Nineteen (42%) of the articles reviewed focused on healthcare providers as the target audience of the KT strategy.11,12,15,16,18,22,23,29–31,34,36–40,43,48,52 The healthcare providers came from diverse backgrounds including clinicians or physicians, nurses, allied health, occupational therapists, midwives, chiropractors and emergency care workers. Seven of the articles (16%) were written with patients as the target population.10,21,26,27,35,53,54 The term ‘patient’ was defined loosely, specific patient populations ranged from concussion patients to epileptic patients to diabetic patients. Three articles (7%) targeted researchers.17,25,41 The remaining articles (n = 14; 31%) targeted multiple populations.13,14,19,20,24,28,32,42,44,46,47,50,51 The most common combination of audiences included patients and healthcare providers14,42,44,47,51 (n = 5; 11%). Caregivers13,24 were included in the target population of two of these multi-targeted studies (4%). The distribution of healthcare contexts and health topics covered was broad. Twelve (27%) of the articles focused on research related to a specific health field, including Chiropractic, Rehabilitation, and Dentistry.10,13,23,26,33,34,36,38,40,41,45,52 Professional development 15,18,24,29–31,37,47–49,53 (e.g. enhancing communication and leadership skills within healthcare teams) was the context for eleven (25%) of the articles. These articles focused on areas such as public health, youth engagement, media and health system management. Policy was another prominent context (n = 10; 22%). Eight

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Online knowledge translation strategies, Katie Mairs et al. Table 1 Summary of final sample of retrieved articles Study design

Country

Target audience/ population

Health topic or context

Ahmed et al.10

Q

NR

Concussion patients

Berger et al.11

D

NR

Bond et al.12

D

Bradford et al.13

References

KT strategy

Outcomes/outputs

F

Clinical Nurses

Rehabilitation; Healthcare supports Hospital

SC

Healthcare professionals

Healthcare system

KM

D

US

Trauma survivors; Care givers

Trauma care

DF

Brody et al.14

Q

US

Cancer treatment

VC

Brooks et al.15 Christopoulou et al.16

Q

UK

Cancer patients; Healthcare providers Midwives

Health education through peer-to-peer interaction; Support Education; Discussion; Implementation of a virtual journal club; Increased accessibility Collaboration; quality improvement; translating evidence to practice Patient-centred care; Information dissemination; Community building Best practices for creating online communities

DF

Enhanced KT

MM

NR

Patients; Healthcare providers

Midwifery communication Health management system

KM

Clark et al.17 Curran et al.18

Q

NR

Researchers

VC

Q

NR

Emergency care workers

Dallest et al.19

D

SC

DiIorio et al.21

MM

US

Epilepsy

DF KM

DiIorio et al.20

QN

NR

Nurses; Midwives; Allied health professionals Researchers; Healthcare providers; Patients Patients

Alzheimer’s research Urban and rural emergency care workers eHealth

Improved health-related information management; Novel portal model Collaboration; Information sharing Creation, acquisition, and dissemination of knowledge Change management; Knowledge management

Epilepsy

KM

Dinh et al.22

MM

AU

ECW

ED

KM

Eaton et al.23 Fenton et al.24

D

AU

Chiropractors

D

CA

Informal caregivers; Healthcare providers

Chiropractics and research culture Communication between caregiver at home and formal healthcare providers

WI BL DF

KM

VC

KM

Self-efficacy; Self-management; Knowledge; support; Improved quality of life Self-efficacy; Self-management; Patient learning Management of information; Learning; Mobilising evidence to practice KT; Open exchange of ideas Increased support for caregivers; Research directions for further development of online support systems

(continued)

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Online knowledge translation strategies, Katie Mairs et al. Table 1. (continued) Study design

Country

Target audience/ population

Health topic or context

KT strategy

Outcomes/outputs

Frame et al.25 Frost et al.26 Greene et al.27 Gruzd et al.28 Hew et al.29

D

NR

Researchers

eScience

VC

Q

I

Patients

Q

NR

Patients

Chronic disease management Diabetes

DF KM FB

Q

NR

Diabetes

BL

Q

US

Healthcare providers; Patients Nurses

Data sharing; Collaboration Informed patient self-management Support; Diabetes guidance and feedback Information; Support

Professional development

KM

Ho et al.30

D

NR

Health professionals

VC

Hoffman et al.31

Q

AU

Occupational therapists

Informing best practices/research Professional development

Househ et al.32 Hoybye et al.33

Q

CA

Drug policy

CT

Q

I

Cancer rehabilitation

DF

Irwin et al.34

D

NR

Researchers; Decision-makers Clinicians; Researchers; Patients Dentists

Dental informatics

VC

Khan et al.35

Q

US

Health promotion

WI

Macdonald et al.36

QN

I

Disadvantaged patients; Community International Society of Travel Medicine

Travel medicine

KM

MacPhee et al.37

D

NR

Nurses

Nursing and leadership

KM

Meenan et al.38 Montano et al.39

D

NR

Radiology

WI

Q

SP

Hospital IT personal; Clinicians Multi-disciplinary clinicians

Hospital

Nagy et al.40

MM

I

Physicians

Medicine

DF VC WI VC

References

VC

Understanding motivators in promoting knowledge sharing; Informed decision making Best practices for development of VC Time efficiency; Structural flexibility; Networking capabilities; Mentoring Information sharing; Group interaction Patient empowerment; Knowledge exchange; Support Social connections; Idea sharing; Research opportunities; Access to information Collaborative community health knowledgebase Clinical problem solving; education; Evaluation; creation of an online list serve How to develop an online knowledge network; Community building; Sharing of information; Increased social capital Knowledge management Collaboration; Social clinical research Information; Advice

(continued)

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Online knowledge translation strategies, Katie Mairs et al. Table 1. (continued) Study design

Country

Target audience/ population

Health topic or context

Nagykaldi et al.40

Q

US

Primary care researchers

Norman et al.42

Q

CA

Omurtag et al.43

QN

Penn et al.44

References

KT strategy

Outcomes/outputs

Primary care/ research networks

CT

Public health; Youth

Youth engagement in health

US

Physicians

In vitro fertilisation clinics

BL CT KM FB TW BL FB TW

D

AU

Patients; Suicide prevention workers

DF

Raman et al.45

Q

US

Sanchez et al.46

D

I

University/ organisation members Researchers; Practitioners

Suicide prevention; Rural and remote communities Emergency response

Enhanced group collaboration and communication Understanding how to engage youth as health promoters through social media technologies; Engagement Recommendations for use of Web 2.0 by physicians; Enhanced communication with patients; Direct information sharing; Support Creation of an online support system

Cancer and public health

KM

Saryeddine et al.47

Q

NR

Professional development and patient education

DF

Stewart et al.48

MM

I

Chronic disease patients; Healthcare providers Midwives

Professional development

CT

Sublet et al.49

QN

US

NIOH Science consumers

Blog visitors/ communication

BL

Sweet et al.50

D

AU

Public health

BL KM

Vera et al.51

D

NR

Healthcare professionals; Media Physicians; Patients

Multiple Sclerosis

DF

White et al.52

D

CA

Occupational therapists

Occupational therapy research

VC

WI

Effective emergency responses/improved procedure Platform to integrate evidence-based practices; Engagement Increased knowledge; Patient support

International connectivity; Access to quality material; Networking Two-way exchange of information on scientific topics Connection between public health and media Communication between physicians and patients; support; Access to information Description of challenges and opportunities for community of practice in remote areas and access to information

(continued)

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Online knowledge translation strategies, Katie Mairs et al. Table 1. (continued)

References Wicks et al.53 Wicks et al.54

Study design

Country

Target audience/ population

Health topic or context

QN

NR

Patients

Epilepsy

QN

I

Patients

Knowledge dissemination and sharing/ communication

KT strategy

Outcomes/outputs

DF KM DF KM

Learning; Support; Social interaction Knowledge gains on: Treatment options, Symptom management and outcomes

Study design: D, descriptive; Q, qualitative; QN, quantitative; MM, mixed methods; Country: AU, Australia; CA, Canada; I, International; NR, not reported; SC, Scotland; SP, Spain; UK, United Kingdom; US, United States; KT, knowledge transfer and translation; KT strategy: BL, Blog; CT, Conferencing Technology; DF, discussion forum; KM, knowledge management strategies; FB, Facebook; TW, Twitter; VC, virtual community of practice; WI, Wiki.

(18%) of the articles had a specific disease focus14,17,20,21,27,28,51,54 (e.g. diabetes, epilepsy, cancer), and four (9%) articles focused on a specific healthcare setting (e.g. hospital, emergency department). Based on articles which reported information on costs,13,15,20,21,32,38–41,44,45,48 technology-based knowledge sharing was, for the most part, identified as either free or of minimal cost, making many of the strategies cost effective. Cost, as a barrier to attending distant conferences or meetings for example, was eliminated through the use of an online knowledge transfer strategy.41,48 Online knowledge transfer strategies were also found to lower personnel costs.13 On the other hand, there may be costs to users associated with start-up and service fees for Internet use.44 Although these costs could be mitigated by the use of Internet services at a library or community centre, they may still present a barrier for knowledge translation.44 The specific health-related knowledge transfer strategies identified through this comprehensive literature review are described in detail below. Knowledge management strategies Various tools were discussed as a ‘system’ or ‘strategy’ to facilitate online knowledge management, which involves gathering, organising and distributing information to an intended audience.19 Ten of the reviewed articles (22%) utilised a knowledge management system as their only strategy for knowledge translation,11,12,16,19,21,22,29,36,37,46

while six (13%) articles used a knowledge management system in combination with another strategy.20,26,42,50,52,53 All knowledge management strategies included an interactive component that allowed users to provide feedback or share knowledge between other members of the target audience. The Managed Knowledge Health Network,19 for example, is an online portal to increase access to information for allied health professionals in Scotland, while also providing them with the opportunity to connect with experts and other healthcare professionals. The knowledge management strategies utilised were most often targeted at the sharing of literature or other practice-based information to and between researchers and/or clinicians. This strategy has been noted to be especially advantageous as it facilitates collaboration of individuals who are often geographically dispersed.19 Importantly, the use of knowledge management strategies has been found to support the development of clinical practice and to enhance care when used by clinicians.12 Virtual knowledge management was viewed as an evolution from established offline strategies for KT. VJC, for example, were cited as a way to bridge limitations of accessibility, to increase reach, and to facilitate sustained collaboration that is often lacking in offline journal clubs.11 From the patient’s perspective, online knowledge management strategies were found to be an inexpensive and easily accessible tool to support their health. They provided a mechanism to connect patients not only to health-related information but

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also to health services and educational resources to support disease prevention, treatment, and management.16,53 This strategy aims to empower patients to take control of their own health by providing them with the information they may need to make important care decisions.54 Patients Like Me, for example, is a platform for patients with life-changing illnesses to share their experience with their condition, to find other similar patients and to share their experiences with one another, and to learn from aggregated data reports of others to improve their outcomes. The goal of Patients Like Me was to help patients answer the question: ‘Given my status, what is the best outcome I can hope to achieve, and how do I get there?’.54 Overall, online knowledge management strategies to facilitate health-related knowledge translation were viewed as an inexpensive, efficient and accessible means to provide not only healthcare professionals but also patients with pertinent health information. Virtual communities of practice Virtual communities of practice also referred to as electronic Communities of Practice, are defined by Nagy et al. (2006) as ‘online forums marked by high degrees of collegiality, sharing of time and resources, interactive and progressive problem solving, and a breakdown of geographical and hierarchical barriers’. Nine of the articles reviewed (20%) utilised a VCoP as their online knowledge translation strategy;14,17,18,25,30,31,34,40,52 one used a VCoP in combination with other strategies.39 Based on both the number of relevant knowledge translation articles identified and the applicability of results provided, VCoPs were found to be a pragmatic way for health professionals, the general public and other key stakeholders to interact and share knowledge. Potential benefits of VCoPs identified in the literature included: time efficiency, structural flexibility, networking capabilities, mentoring opportunities31 and access to information.14 In addition, members of a VCoP are able to access these virtual forums at their convenience, unrestricted by geography or physical conditions.14 VCoPs also provide an interactive forum for researchers or clinicians to work together within a protected environment to share data, develop

thoughts and discuss ideas.30 They allow researchers to share information with very little added effort, at a high value return, while introducing participants to new clinical experts and resources.18 They also provide a mechanism for the research process and progression of work to be documented in a way that is easy for new members to understand.30 This may facilitate greater uptake of best practices by individual health professionals and promote intra- and interprofessional continuing professional development and team-based, patient-centred care. Nagy et al. (2006) suggests that excellence in five areas explains the most successful VCoPs: educational content, discussion, involvement, energy and credibility. Additional literature suggests that the more homogeneous, or focused a community of practice (CoP) is on topics that are of interest the members, the more involved the members are likely to be.14 Trust was also found to be an important component of a successful VCoP. Specifically, trust between members is more likely to occur when members share a common purpose and when they are provided with the opportunity to get to know one another.17 Trust is seen as very important in VCoPs, as a factor necessary to generate meaningful communication.14 Finally, the literature suggests that for a CoP to be successful and sustainable and to have the knowledge be applied to practice, frontline practitioners or other health professionals who actually use the knowledge should be involved.52 Discussion forums A discussion forum (also known as a discussion group, discussion board, message board or online forum) is a general term for any online ‘bulletin board’ where you can leave and expect to receive responses to messages left. Seven of the articles (16%) reviewed employed a discussion forum as their only strategy of online knowledge translation.13,15,24,33,44,47,51 This strategy was also considered by some articles to be a component or building block of a VCoP.15,44 The social nature of discussion forums has been described as a key component of their success, as many factors relating to social conduct in face-to-face situations can be applied in the virtual world.51 Brooks (2006) elaborated on

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this finding that there was benefit to the virtual communication among healthcare professionals in discussion forums, allowing users to express opinions without normative pressures of face-to-face interaction. Discussion forums can also enable the formation of new relationships and can strengthen existing ones, creating a sense of community.13,44 Communicating with others in similar situations or with similar needs, particularly for individuals attending online self-help groups, was found to be an important feature of discussion forums.13,44,53,54 For example, discussion forums (as a form of social networking) have been successful in bringing people with multiple sclerosis together from around the world and has facilitated the distribution of personal experiences and the sharing of medical information.51 As a result, there has been accelerated growth in the number of patients seeking treatment for this syndrome, despite the possibility that it may not improve their present condition.51 An additional discussion forum, built into the website MyJointReplacement.ca, was initiated to integrate patient and provider perspectives with evidence on joint replacement care into a patient education website to promote consistency in practice.47 Results of Saryeddine et al. (2008) study found that providers perceived the site to contain up-to-date knowledge on best-practices in joint care, and felt confident referring their patients to it. Patients also found the website and its discussion forum component helpful for them to easily access pertinent information.47 Similar to VCoPs, trust was found to be an important mediator of discussion forum use.14 Trust in the information provided, also discussed as quality control,37 facilitates the creation and translation of knowledge,14 and can be fostered by having support from experts in the field.37 Using password protection and enforceable policies informing members of their responsibilities can assist with quality control.37 Conferencing technology Virtual conferencing technology connects individual across geographical barriers. Also known as web conferencing, webinars or online workshops, this strategy refers to a service that allows conferencing events to be shared with individuals who

are geographically dispersed.32 In general, the service is made possible by Internet technologies, allowing real-time point-to-point communications41 as well as multicast communications from one sender to many receivers.32 It offers information from text-based messages, voice and/or video chat to be shared simultaneously, across geographically dispersed locations. Applications found in this review for virtual conferencing included the hosting of meetings, training events, lectures or short presentations.32,41,48 Four articles reviewed utilised this strategy, three as their only reported means of knowledge translation,32,41,48 and one in combination with other technologies.42 Conferencing technology exists in a variety of platforms, some with basic audio functioning21 and others with visual capabilities.41 Househ et al. (2010) noted that conferencing technology that did not have a visual component limited group communication when first introduced because it allowed only one person to speak at a time. Beyond this, one type of virtual conferencing technology identified in this review, Access Grid (AG) technology, was used to facilitate board meetings and allowed members who were in different locations to see one another.41 Through this technology, it was found that face-to-face interaction facilitated better communication among participants. Another benefit of this online KT strategy was its ability to save users time and money associated with travel.41 In general, enhanced social interaction of groups because of ease of communication and ability to have meta-communication (visual cues) was a benefit of using conferencing technology with a visual component.41 In a study by Stewart et al. (2012), virtual conferencing was used to conduct annual conferences for healthcare professionals within the midwifery field. This online conference provided midwives with the opportunity to network and to share research and practice-based information. It was found that participants ‘appreciated the opportunity to be able to network with colleagues in an international context, believed the event provided access to quality material and presenters, and valued the accessibility and availability of the event and resources’. However, it was suggested that the use of this technology could be improved by providing information to users about appropriate

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netiquette (rules or accepted behaviours for communicating on the Internet).48 Discussion Health-related KT may be viewed as ‘the bridge that brings together continuing medical education, continuing professional development and quality improvement in the hope of closing the researchto-practice gap’.55 Knowledge translation not only allows attention to be given to multiple stakeholders across healthcare practices, including patients, consumers and policy makers, but facilitates the transfer of high quality research evidence into effective changes in health policy, clinical practice or products.55 To the best of our knowledge, this is the first systematic search and review examining online techniques to facilitate health-related knowledge transfer. The most commonly cited online knowledge translation technique identified in this literature review was the use of knowledge management strategies or systems, followed closely by discussion forums, and VCoP. Generally used as a knowledge translation tool for professionals (healthcare workers and researchers), knowledge management strategies were found to have a variety of benefits to users including providing an effective means to translate evidence to practice12 allowing researchers and clinicians to collaborate,12 assisting with clinical problem solving and education36 and even promoting community building and increasing social capital.36 These systems were also used to facilitate collaboration across populations, between researchers and healthcare providers,21,46 as well as including patients in the translation of knowledge.16 For patients, knowledge management systems have been found to increase self-efficacy, selfmanagement and patient learning.20,21 Support and social interaction were also noted as benefits of knowledge management systems because of the social component of many of these systems.53,54 Barriers to this technology include getting people to use the systems and teaching new users to get the most out of the systems and provide feedback so that they can be improved.19 In this review, knowledge management systems existed across a variety of platforms including

online list serves, databases, portals, e-Libraries, VJC and/or combinations of these. Berger et al. (2011) discussed one example of a successful knowledge management strategy, the VJC, as an implementation in a clinical nursing setting allowing staff to access information and engage in discussion and team building at their own convenience. Nurses reported that the VJC offered them a non-threatening environment to engage with the literature and understand how proposed best practices could be applied in their own clinical settings.11 A challenge of knowledge translation is that it involves the complex process of acquiring, converting, and applying a combination of explicit and tacit knowledge in clinical activities.56 The CoP, a concept identified to understand how people learn,57 has been used by an increasing number of groups and teams in the health sector to help practitioners make sense of the concrete information (e.g. practice guidelines) in the context where it is used. CoPs have now become active online, evolving into VCoPs but maintaining key elements including providing members with social interaction, knowledge sharing, knowledge creation and identity building.56 Virtual communities of practice have been found to be an effective means of collaboration and information sharing,17 and in the creation, acquisition and dissemination of knowledge.18 Rural and remote healthcare workers have been brought together through the use of VCoP.58,59 Although there have been many benefits of VCoPs highlighted, ethical challenges including ideas of identity and deception, privacy and confidentiality have been identified.60 Technical issues involving usability have also been noted in the literature.60 To overcome these issues, when practitioners utilise VCoPs to communicate with patients or colleagues they are encouraged to be aware of the challenges and maximise sociability and usability of this tool, while addressing concerns for privacy, and the lack of clarity or relevance of current legislative frameworks.60 Discussion forums have been recognised as particularly advantageous in translating knowledge to practice, as they are practical, timely and result in little or no cost to the user.58,59,61 They are useful for healthcare providers to enhance practice by

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engaging in reflective discussion and share information.15 They provide a mechanism to link relevant stakeholders and have been shown to be an important factor in patient support, particularly for those with chronic conditions.62 The development of discussion forums by healthcare organisations and networks could facilitate further collaboration among stakeholders (including clinicians, researchers, policy makers and patients) with interests in an array of health-related topics. For example, according to a survey by Klemm et al. (2008), 41% of e-patients have read someone else’s commentary or experience about health or medical issues on an online news group, website or blog. Health consumers are often looking for tailored information, searching for a ‘just-in time someone-like-me’ experience.62 Discussion forums can offer this to patients. They could also enable effective and efficient sharing of health information to others both nationally and internationally. Based on the literature, to ensure that this strategy would be successful, it is important that the forums facilitate the linkage of members who have comparable circumstances, needs or interests17,63 and demonstrate an atmosphere of trust through the inclusion of research experts.63,64 Saryeddine et al. (2008) note that an important limitation to Internet based discussion forums is access to the Internet. They suggest having alternative means of knowledge translation available to patients who do not have Internet access such as print media and DVDs. Other knowledge translation strategies acknowledged, such as wikis and blogs, were viewed as more limited in their capacity to facilitate the translation of knowledge into practice. However, as both methods remain more dynamic than a website itself, they are still considered as efficient modes of research dissemination. They may be particularly advantageous over a website in that they are easy to use, can be created and deployed expediently, and provide an opportunity for information exchange.65 The fact that there are many free and open source versions of these tools available may also be responsible for their continued growth.65 Several wikis currently exist within the health field, including the ‘Flu Wiki’ which was created to help local public health communities prepare for avian influenza pandemics66 ‘Wiki Surgery’ which is a free surgical encyclopaedia for surgeons and their

patients,67 and RadiologyWiki.org which is used as an online radiology educational resource.68 However, one unfortunate downfall of wikis and blogs is that with virtually anybody able to alter, edit or contribute to these collaborative ‘webpages’, it can be problematic to gauge the reliability and accuracy of such resources.65 Considering the growing popularity and use of social media, including Facebook and Twitter, it is not surprising that these platforms were identified as strategies to facilitate health-related communications between broad populations of users. It has been suggested that social media has ‘increased individual’s connectivity and enabled user’s direct participation’.69 In particular, as social networking sites attract a significant portion of Internet users, it makes them an obvious target for maximising the reach and impact of health communications and eHealth interventions.69 Twitter has recently grown in popularity as a source for health information as ‘users can follow health conferences, a developing health story, search for information or share web links instantly from their desks or mobile devices. Searching for any health topic on Twitter leads to new contacts, networks and information’. Within the current literature review, social media was used as a means to engage youth in their own health, to support diabetes management, and to share information between physicians and patients attending in vitro fertilisation clinics. Information overload was a common theme threaded throughout many of the online strategies identified through this review. Studies examining the effects of information overload have found that it often leaves users feeling distracted and stressed as they attempt to navigate through, and deal with, excessive information.70 It is important to design a KT strategy that ensures users can easily find the information or resources they need – this can be achieved by understanding the requirements of the users.71 For example, for practitioners, the ‘absolute risk reduction’ is an important term to include when describing results.72 As a general rule, all information posted for the general public should be easily comprehensible, concise and clear.73 Furthermore, restricted areas that are only accessible by smaller groups of specific members can be created to facilitate the sharing of more specialised information or research. Several strategies to reduce

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information overload and to enhance the translation and exchange of knowledge have been identified. One such strategy is the Semantic Web, which minimises information overload as it aids in filtering more relevant results for the user.74 Although rigorous and systematic techniques were applied to this search, some literature regarding strategies to facilities online knowledge translation may not have been identified. The developed search strategy focused only on articles available in English, potentially capturing a more limited range of the available online knowledge translation resources. The abundance of methodologically descriptive articles reviewed in this paper may contribute to a possible difficulty in generalising findings. However, because this is a field in its early stages, the authors believe that these papers provide valuable insight into the development of online strategies for knowledge translation. Due to the rapid technological changes that have occurred within the last decade, our search was limited to articles published since 2003. Therefore, the broad trends presents within the technologically enabled knowledge translation field are reflective of recent developments but do not provide a picture of trends in the field since its inception. Our search strategy focused on peer-reviewed journal articles; a review of the grey literature could be considered for future research. In terms of strengths, as the translation and exchange of knowledge spans many disciplines, our decision to include four prominent databases strengthened our ability to obtain relevant articles that may not have been captured otherwise. Our review followed a rigorous, systematic application of inclusion and exclusion criteria based on an accepted research question structure and a detailed approach to coding guided by the needs of our presumed stakeholders.75 This ensured that appropriate criteria were developed which facilitated the selection of relevant citations. All of the studies reviewed have found that the development of multiple communication and knowledge sharing technologies has facilitated the translation and exchange of knowledge. Due to the methodological limitations of this emerging literature, further research is needed before stronger recommendations can be made regarding the efficacy of these strategies to support knowledge transfer.

Conclusions Knowledge translation is becoming a critical component of the healthcare field, and online technologies are emerging as a key facilitator of efficient and timely knowledge exchange. Through online technologies, it is possible for stakeholders to share health knowledge regardless of geographical constraints, thus encouraging the advancement of knowledge in health and other fields. Our study provided a review of online strategies for knowledge translation from a range of countries and across diverse fields of application within the area of health and healthcare. It is hoped that this review may help to inform the development and improvement of future online health-related knowledge translation strategies. Acknowledgements The authors thank the University of Waterloo’s Health Sciences Librarian Jackie Stapleton for her expertise in the development of the search methodology. This study was funded in part by a grant from the Canadian Institutes of Health Research to establish the Canadian Dementia Knowledge Translation Network. References 1 Government of Canada. Canadian Institutes of Health Research. [Internet]. 2009 [updated 2013 May 15]. Available from http://www.cihr-irsc.gc.ca/e/39033.html (accessed December 15 2010). 2 LaRosa, J., He, J. & Vupputuri, S. Effects of statins on the risk of coronary disease: a meta-analysis of randomized controlled trials. Journal of the American Medical Association 1999, 282, 2340–2346. 3 RAND. The first national report card on quality of health care in America. RAND HEALTH [Internet]. 2006. Accessible at: http://www.rand.org/pubs/research_briefs/RB9053-2/ index1.html (accessed June 15 2013). 4 Ho, K., Chockalingam, A., Best, A. & Walsh, G. Technology-enabled knowledge translation: building a framework for collaboration. Canadian Medical Association Journal 2003, 168, 710–711. 5 Hall, A. & Walton, G. Information overload within the health care system: a literature review. Health Information and Libraries Journal 2004, 21, 102–108. 6 Arora, N. K., Hesse, B. W., Rimer, B. K., Viswanath, K., Clayman, M. L. & Croyle, R. T. Frustrated and confused: The American public rates its cancer-related information-

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