Use of the PDQ system in a clinical setting By Jennifer J. Angier, M.L.S.*
Angier Associates 2360 North 57th Street Seattle, Washington 91803 Susan L. Beck, R.N. Clinical Nurse Specialist Harmon J. Eyre, M.D. Professor of Medicine, Division of Hematology-Oncology Utah Regional Cancer Center University of Utah Health Sciences Center Salt Lake City, Utah 84112
This pilot study examined the use of PDQ (Physician Data Query)-a user-friendly, full-text, cancer database-as a clinical information resource on an oncology unit. The twenty-nine participants included faculty, hematology-oncology fellows, residents, interns, medical students, pharmacists, and nursing staff. During the one-month study, PDQ was available twenty-four hours a day at the nursing station via a microcomputer. Participants were trained to use PDQ and allowed to search the database as prompted by clinical situations. The project evaluated the use of PDQ, as well as clinicians' perceptions of its usefulness. Results indicate that access to PDQ on an oncology unit provides an excellent educational and clinical resource. Fifty-one percent of the participants used PDQ an average of 2.4 times each. Heaviest users were medical trainees (78%), although 39% of nurses became users. Over half of the PDQ users reported that use of the database affected clinical care.
INTRODUCTION PDQ (Physician Data Query) is a user-friendly online database produced by the National Cancer Institute (NCI) to communicate current information on the diagnosis and treatment of cancer. Designed for use by physicians, it provides access to full-text, state-ofthe-art consensus statements from a board of recognized oncology experts, information on clinical trials, recent cancer literature, patient information, and a directory of oncology researchers and organizations [1-3]. Clinical personnel operate in a sophisticated, rapidly changing environment strongly influenced by research discoveries published in over 6,000 biomedical journals. Keeping current with the literature is a difficult and time-consuming process. Phy*
Formerly, head of Hope Fox Eccles Clinical Library, University of Utah Health Sciences Center, Salt Lake City, Utah 84112. Bull Med Libr Assoc 78(1) January 1990
sicians, nurses, and other allied health professionals often lack the time to pursue specific inquiries and frequently lack the skills to efficiently access the variety of resources available to them. In addition, the abundance of information in no way guarantees its quality or reliability. This paper presents the results of a pilot study for the University of Utah Medical School Project to examine the use of the PDQ system in the clinical setting. The overall project was supported by an award of 150 unbilled hours of PDQ system time from the National Cancer Institute. The University of Utah project explored the use of the PDQ system as a clinical and educational information resource in the inpatient setting. The study was designed to provide centralized access to the database on a twenty-four-hour basis and to identify which clinical staff and students used PDQ, and for what purposes. In addition, clinicians' perceptions of the system's usefulness in terms of day-to-day activities on the unit were investigated. 15
Angier et al.
REVIEW OF THE LITERATURE
Several studies have documented barriers to the use of published information in support of patient care activities [4-6]. Libraries have sought to bridge the gap between the need for patient care information and the difficulties of using traditional resources by developing clinical medical librarian programs. Clinical medical librarian programs are specialized services designed to provide an immediate response to case-related information needs and usually involve the assignment of a reference librarian to a patient care team. The librarian serves as a literature specialist on rounds or during other case conferences. In this manner, barriers to using traditional library services may be overcome by bringing the information relating to individual patients directly to clinicians. The effects of using the literature on patient care have only recently received systematic study [7]. The earliest studies evaluated clinical medical librarian programs and generally confirmed the convenience and time-saving benefits of these programs, as well as indicating a strong contribution to patient care [813].
Physicians, nurses, and other allied health professionals often lack the time to pursue specific inquiries and frequently lack the skills to efficiently access the variety of resources available to them. Clinical medical librarian programs are one method of providing access to the most current information. However, the large commitment of personnel time required to staff these programs limits their application in many clinical situations. An alternative to exclusive reliance on a human information specialist would be the location of user-friendly computerized information resources at the site of clinical care. The system would be supported by a literature specialist who would provide training, serve in a problem-solving capacity with individual users, and provide indepth literature searching backup as required. In 1982 Matheson and Cooper predicted that clinical medical librarian programs would stimulate the development of automated literature files accessed on terminals located in clinics, nursing stations, and physicians' offices [14]. As of May 1987 (the completion of the pilot study), the published literature contained no reports on the placement of a full-text or bibliographic database on a working inpatient unit. Nipper automated a variation of the clinical medical librarian program called LATCH (Literature Attached To CHarts) by using the hospital information system to relay requests for information to the library [15]. 16
Photocopies of articles were then attached to the relevant patient chart for use by all unit staff. The problem of wider, convenient access to information was
addressed by this system, but immediate delivery of the full text of the article is still an issue. NCI estimates that application of state-of-the-art treatment could reduce cancer mortality rates by 10% to 15% [16]. Stross and Harlan have identified several difficulties in the widespread dissemination of research discoveries through publication and continuing medical education to practicing physicians [17]. PDQ was developed to bridge the gap between research advances and practice applications and to serve as an easy-to-use resource representing the highest standards of care.
PDQ was developed to bridge the gap between research advances and practice applications and to serve as an easy-to-use resource representing the highest standards of care. The authors hypothesized that direct, immediate access to PDQ at the place where patient care activities occur would overcome many of the barriers to literature use encountered by clinical staff. It would also ensure the availability of information to an interdisciplinary staff regardless of work schedule. Because PDQ contains peer-reviewed information from the NCI, it serves as a high-quality resource with strong relevance to the patient care and educational activities on an oncology unit.
METHOD Design. The study was designed to evaluate the use and value of PDQ when it was made accessible to clinicians twenty-four hours a day for a month-long period. Participants were provided with the basic tools for using PDQ, including instruction on system commands and file content. Data were collected to measure system use and assess the value of PDQ to clinical activities. Primary interest was in identifying whether PDQ was used, how it was used, and by whom, as well as whether successfully located information was considered useful to patient care. Sample and setting. Participants included twentynine clinical staff and students engaged in patient care activities on a twenty-four-bed oncology unit at a university hospital. All staff and trainees assigned to the unit were notified of the opportunity and encouraged to participate voluntarily in the project. The study period extended from May 1 to May 31, 1987. Bull Med Libr Assoc
78(1) January 1990
The PDQ system
Procedure. Equipment to access PDQ was located at the nursing station on the unit and consisted of a Macintosh Plus with a twenty-megabyte hard disk, a 1200-baud modem, and an Imagewriter II printer. Red Ryder (version 9.4) telecommunications software was loaded onto the hard disk to eliminate the need for inserting a floppy disk for each terminal session. An automatic log-on procedure was programmed to reduce user involvement with complicated access and log-on protocols and diminish the technological aspects of using PDQ that did not relate directly to the system. For user assistance, the PDQ manual was located next to the terminal, along with a laminated user aid sheet that listed troubleshooting tips, the password, manual log-on techniques, and the library and home telephone numbers of the clinical librarian serving as the twenty-four-hour resource person. Training to use PDQ was provided by the clinical librarian and consisted of a thirty-minute session that covered the basics of file content, use of the menus, basic commands, logging on, and disconnecting. A sample search was conducted in the four files that make up the PDQ system: the Cancer Information file, the Protocol file, the Physicians file and the Organizations file. A total of twelve training sessions of one to four participants was held. At the completion of the training sessions, the clinical librarian withdrew from the unit to allow participants to search without interference but remained available if problems developed. Instruments. Three instruments developed by the investigator were used in the study. A short questionnaire was administered at the beginning of each inservice training session to collect baseline data on awareness of the PDQ system, as well as user experience with computer equipment and database searching. Responses to this survey were used to assess the relationship between previous experience and subsequent use of PDQ. A daily log sheet was designed to provide descriptive data on use of the system. The log sheet documented each terminal session according to who used the system, the purpose(s) (e.g., to increase knowledge, to support a specific clinical decision, for patient referral, to locate an expert consulting clinician/researcher, etc.), whether the database contained information addressing each purpose, and, finally, how much time elapsed during the search. The length of each terminal session was of interest for evaluating individual search time, as well as for accounting purposes. A structured interview with open-ended questions was administered to each participant to assess perceptions of the usefulness of PDQ in the clinical setting, expanding on the information collected at the terminal. The concept of usefulness focused on the Bull Med Libr Assoc 78(1) January 1990
Table 1 Frequency of PDQ use according to type of professional training Professional training
Total trained
PDQ use
A. Medical (MD) 1. Faculty/attending 2. Fellow 3. Resident 4. Intem 5. Medical student B. Nursing 1. MSN 2. BSN 3. RN 4. LPN
9
7 (78%) 0
1 1 1
C. Pharmacy
3 3 18 2 8 4 4 2
Total
29
1 1 2 3 7 (39%) 1 3 2 1
1(50%) 15(52%)
purpose prompting each use, as well as the ease of use, the sufficiency of knowledge contained in the database, the format of the information and the method of access. Participants who did not use PDQ during the study period were also interviewed to determine barriers to using the system. Nonusers were not prompted by any cues from the interviewer and explained their lack of participation in their own terms.
RESULTS In thirty-one days, the PDQ system was used thirtysix times for an average use of 1.16 times per day. Of the twenty-nine study participants, fifteen (52%) used the system. Each user averaged 2.4 uses of the system each. Table 1 shows the breakdown of users by clinical discipline. In the case of medical trainees and staff, 78% of those trained to use the system became users; 39% of nursing staff became users. Other study participants included two pharmacists assigned to the unit; one of them used the system. Of the fifteen individuals who used PDQ on the unit, eight were clinical staff and seven were students in training. Use of the system was higher by trainees (twenty-one sessions) as compared to staff (fifteen sessions). Table 2 Frequency of PDQ use according to prior experience and type of professional training Use of
Professional
Computer
training
experence
Medical (MD) Nursing
8 (6)* 15(7) 2 (1) 25 (14)
Pharmacy Total *
PDQ search experience intermediary awareness Searching 5 (4) 3(2) 0 (0) 8 (6)
4 (3) 6(2) 2 (1) 12 (6)
3 (2) 5 (3)
0 (0) 8 (5)
(N) = Became subsequent users.
17
Angier et al.
Table 4 Frequency and percent of positive perceptions of specific characteristics of PDQ usefulness (N = 15 users)
Table 3 Frequency of reasons for PDQ use and search results InformaReason 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
General information Drug information Treatment information Prognosis information Diagnosis information Protocol information Staging information Patient statement Other Referral information Total
Found Information Times information reported' adequate
13 3 2 2 2 1 1 1 1 0 26
11 1 1 2 1 1 1
11 1 1 2 1 1 1
0
0
1
1 n/a 19
n/a 19
tion neces-
sary2 11
3 2 2 2 1 1 1 1 n/a 24
1 Study participants may have reported more than one reason for searching
PDQ.
Information was considered "necessary" if user would have pursued the search via another source if PDQ had not been available or if their PDQ search was unsuccessful.
2
The study used approximately twenty hours of online search time: 12.4 hours for training purposes and 7.6 hours for searching PDQ by unit staff and students. On average, each search was 14.3 minutes long, with a median length of 10.5 minutes. In Table 2, the information obtained from the baseline questionnaire is related to subsequent PDQ use. An odds ratio test was applied to the data collected from the preliminary questionnaire to determine whether an association might exist between prior computer experience, end-user experience, previous use of a search intermediary or PDQ awareness prior to training, and subsequent use of the database. No significant association was found.
By far the greatest use was to find general background information on a specific diagnosis. Four individuals described their initial use as curiosity, although each of them was prompted by a real information need. PDQ users accessed the database for all available types of information (Table 3) except for referral purposes. By far the greatest use was to find general background information on a specific diagnosis. Four individuals described their initial use as curiosity, although each of them was prompted by a real information need. Three of those individuals went on to search the file again for additional reasons. Only the individual who was unable to find relevant information did not use the file again. 18
Characteristics 1. 2. 3. 4. 5. 6.
Easy to use Menu format useful Saved time Reliable access Display format useful Affected clinical management
Positive responses (%) 13(87%) 12(80%) 11 (73%) 11 (73%) 10(67%) 8(53%)
Users reported success finding information related to their query 73% of the time. In every case when information was successfully located, the information was judged to be adequate. All but two terminal sessions were prompted by an information need that was considered important enough for the user to have pursued it elsewhere had PDQ been unavailable or if their PDQ search had been unsuccessful. The positive responses of the fifteen PDQ users to questions relating to the usefulness of the database are summarized in Table 4. Over half felt that information retrieved from PDQ affected clinical management. In six of the eight positive responses, the users felt they approached individual patients in a generally more-informed way. Two individuals related specific clinical decisions that were affected by use of the file. Although most users of PDQ found information adequate to their needs, general comments during follow-up suggested additional areas for content expansion. Five nursing and medical staff users suggested adding general information on antineoplastic drugs, their side effects, and toxicity. One medical resident suggested that adding information on generic classes of drugs used for chemotherapy would be especially useful for patient care. The resident and the hematology-oncology fellow who participated in the study felt that the hematological diagnoses were too limited for their use. For example, they were unable to find information on myelodysplastic syndrome (preleukemia syndrome). Both nursing and medical participants were also interested in searching different diagnostic information in PDQ. They found the entry point of a specific diagnosis to the Cancer Information file limiting in the case of patients who were admitted with no diagnosis. Nursing staff suggested adding information on symptom management, as well as bedside care and assessment. Seventy-three percent of PDQ users reported that using the database saved them time. It was considered convenient since they did not have to leave the unit to visit the library, search through a personal library, or locate a knowledgeable colleague. Respondents who did not perceive that PDQ saved them time were Bull Med Libr Assoc 78(1) January 1990
The PDQ system
Table 5 Frequency of reasons for not using PDQ (N = 14 nonusers)
1. 2. 3. 4. 5. 6.
Table 6 Patterns of PDQ use by day and time (N = 37 uses1)
Reason
Times reported (%)t
Characteristic
Frequency
No time No opportunity2 No need Another user performed search3 Fear of using computer Not considered helpful
4(29%) 4(29%) 3 (21%) 2 (14%) 2 (14%) 1 (7%)
Day of the week Weekday (M-F) Weekend (Sa-Su) Time of the day 6:00 A.M.-noon 12:01 P.M.-6:00 P.M. 6:01 P.m-midnight 12:01 A.M.-6:00 A.M.
30 7 5 16 13 3
1 Participants may have reported more than one reason. 2 Defined as not scheduled to work on the unit for at least 50% of the study.
3In the case of two nurses, their queries were searched on PDQ by a third staff member.
frustrated by log-on problems, program loops while using the system, or lack of knowledge of the content limits of the database. In general, users found the menu system useful (80%). Users commented that menus made the system easy to use and eliminated the need to memorize searching commands. Two thirds of the users (67%) also found the format of the displays valuable. They had little trouble locating the specific information required within the sections of the file selected for display. Several users commented that printing the information for study in detail at a later time was an important advantage. Eleven of fifteen PDQ users also felt that telephone access of PDQ was reliable enough for use in the clinical setting. During the study, PDQ was accessed on a telephone line that was required periodically for unit business. In general, PDQ use did not conflict with unit business, but disconnects and log-on problems increased during peak business hours (10:00 A.M. to 4:00 P.M.). Fourteen study participants did not use PDQ during the month. The explanations given by nonusers during follow-up are summarized in Table 5. During the study period, four individuals felt that they had had no information need or that PDQ would not be helpful to them. Another four were extremely limited in their opportunity to use the file. Two were scheduled to work on other units for most of May. One person worked only one day per week, and one was on vacation for two weeks. Six study participants had originally planned to use PDQ: four felt hampered by lack of time while on duty; two were intimidated by having to use a computer. Two nursing staff were indirect users of PDQ. Their queries were searched by a third nurse who was enthusiastic about microcomputers, PDQ, and database searching. However, since none of the five terminal sessions they reported were logged on the daily sheets, these sessions were not included in the formal analysis. Bull Med Libr Assoc 78(1) January 1990
I Three PDQ users who logged terminal sessions were not part of the original study group; they were self-trained or trained by other staff. Those sessions are included in this table. Two study participants logged no specific sessions and could not be included in this table.
During follow-up interviews, users reported several problems using PDQ. The majority of problems (83%) concerned telecommunications, in particular the automatic log-on procedure. Comments described general difficulty with getting the Red Ryder program to work, but lack of user sophistication prevented a more specific diagnosis of the problem. A review of the daily log sheets indicated that there were only three completely unsuccessful log-ons reported (8%). However, additional problems were reported during the follow-up interviews, and several users stated that they did not record sessions in which they were unable to log-on. One study participant never logged any of his several attempts to access PDQ. A seventh user also had difficulty with the Red Ryder software: she was unable to initiate the print command successfully. Two users reported problems with line noise and disconnections. Only one individual reported equipment problems. The paper feed on the printer slipped frequently, resulting in a jam. Six users (40%) reported problems using the PDQ program software. One individual complained that response time was slow during one session, and a second found the displays too long. Four users reported problems with "program loops." After responding to instructions to select the number of an item to be printed or to select from a menu to continue a search, PDQ would return to the same menu or set of instructions and repeat the prompt. Three users who experienced this problem stated that disconnecting was the only way to break the loop; a fourth user reported that the program corrected itself after a number of repeat selections. Logging on after disconnecting corrected the problem in the case where instructions to select from the menu resulted in a loop. In the two cases, both in the Protocol file, the loops occurred a second time. Both users reported high frustration at apparently locating what they needed without being able to display the results. PDQ use occurred primarily on the weekdays (81%) 19
Angier et al. Figure 1 Frequency of PDQ use for each day of the week Total Number of Uses
May 4-31, 1987
9 T,
Su
M
Tu
Th
W
F
Day of Week
and between noon and midnight (78%) (Table 6). The weekly pattern (Figure 1) suggests that use of the system follows the same course as admissions to the unit. The greater number of admissions early in the week would prompt increased information needs over the course of the week as treatment progressed, which would taper off as patients were discharged for the weekend. DISCUSSION
PDQ was used primarily by medical trainees, but also by nursing and pharmacy staff. The highest use was by the third-year medical students who found the system to be an excellent and convenient educational tool for specific clinical situations. Both the attending faculty and the hematology-oncology fellow participating in the study stated that they would use the system regularly, though less often, and as a clinical, rather than educational resource. Use by medical personnel was an expected result of the study since the system was originally designed for physicians. However, use by nurses and pharmacists (all staff rather than students) confirms PDQ's potential as a clinical information resource for other patient care providers. The sufficiency of the knowledge base in this system needs to be studied in more detail. The average 20
use of PDQ in this study was 2.4 times per user. However, the reasons for successful multiple use may relate as much to an individual's growing understanding of the database content and its limits as to the actual sufficiency of knowledge for use in the clinical setting.
Use by nurses and pharmacists (all staff rather than students) confirms PDQ's potential as a clinical information resource for other patient care pro-
viders. There was no association between individuals who used PDQ during the study and prior computer experience, awareness of PDQ prior to training, previous use of an intermediary, or their own database searching experience. One explanation for this result at the University of Utah may be the high exposure of health sciences practitioners and students to automated systems. The Health Sciences Center at the University of Utah is a site for one of the National Library of Medicine's IAIMS (Integrated Academic Information Management System) projects. As a result of this project, hospital personnel and students Bull Med Libr Assoc 78(1) January 1990
The PDQ system
in training are exposed to a variety of electronic information systems, even if they do not use them regularly. Accessibility to a computerized resource may not in itself provide the motivation to use it at this location. In addition, the Spencer S. Eccles Health Sciences Library has been providing MEDLINE and other database searches through a librarian intermediary for over a decade. Use of an intermediary is a convenient method of collecting bibliographic information and may eliminate the need for an individual to search themselves. However, it would seem reasonable that clinicians or students who are motivated to learn to use a computer to search a database such as MEDLINE themselves are likely to be prompted to use a specialized electronic database such as PDQ. Awareness of PDQ prior to the study might also stimulate interest in trying the database. This was not supported by the data. However, the sample size of this study may have been too small to detect this relationship, and further study with a larger population is warranted. In addition, examination of possible associations between nonuse of PDQ and lack of previous experience with computers, PDQ awareness, prior use of an intermediary, or previous database searching experience may provide interesting perspectives on potential barriers to using the database. Another explanation for a result of no association between prior computer or database searching experience and use of PDQ may be that lack of experience is not a barrier to use. In this study, 87% of PDQ users found the system easy to use, and more than half of the total participants were comfortable enough to try it after one thirty-minute training session. A review of the daily log sheets showed that PDQ users accessed the Cancer Information file 6.5 times more often than the Protocol file, suggesting that background knowledge about a diagnosis was of most use to the participants of this study. This finding is consistent with the observation that the number of student terminal sessions was almost twice that of staff. The University of Utah Hospital is a tertiarycare teaching hospital in which several levels of students are assigned to the oncology unit every four to six weeks. For these individuals, cancer patient care is a new experience and offers a tremendous learning opportunity. Permanent clinical staff need background information as well, but may require it less frequently. Locally approved protocol information is readily available to students and staff in a notebook on the oncology unit. In general, this printed source is easy to consult. Since so many patients are admitted to specific protocols, the PDQ Protocol file would be used to search out a new protocol or consider another method of treatment in a patient not responding to the current one. Bull Med Libr Assoc 78(1) January 1990
The Physicians and Organizations files were not searched at all during the study period. This is not unexpected since the institution serves as a tertiarycare hospital and accepts more patients than it refers for cancer treatment. Evaluation of the use of these files might be more meaningful in the community hospital or office-based practice setting. Reasons reported by participants who did not use PDQ may provide valuable information for developing this database in particular and for implementing electronic services on an inpatient unit in general. The results of this study suggest that time and opportunity may serve as significant barriers to some individuals who originally intended to use the service. These results are similar to studies of more traditional use of the literature [18-20] and call for closer examination. Since the methods used in this study are biased to reporting use rather than nonuse, a more extensive investigation of nonusers might focus on determining whether these constraints also cover an underlying lack of interest or need, an insufficiency in the database, problems with equipment or software, fear of computers, or inadequate training in the use of electronic systems.
Busy clinical people must be strongly motivated to learn something new and need to perceive the learning as necessary to their practice. Problems encountered while using PDQ can only be identified and described by this pilot study. Several participants reported that they recorded only successful log-ons on the daily log sheets; thus, the usage analysis may actually be an underestimate of the use of PDQ. A closer examination of how far users who did not successfully log-on got in the process of accessing PDQ would provide valuable information for continuing to remove potential barriers for use. Program loops should be further documented. The frustration level of users who could not display the results of a search while apparently responding correctly to system prompts was high. This could prevent an individual from continuing to use PDQ. PDQ was perceived as useful by the participants in this study, and more than half of the PDQ users in the study reported that it affected clinical care. This is similar to the results of King, Scura, and Davidoff, and Stearns et al. In patient care examples related by two study participants, information from the database actually resulted in a specific management decision. Further study to evaluate more specifically the effect of PDQ on clinical decision making is warranted. More sophisticated criteria for defining the effects of an 21
Angier et al.
electronic reference service on cancer treatment need to be determined and measured. Reports that use of PDQ saves time is another significant indication that clinicians found the system useful. Eliminating log-on frustrations and program software loops will further enhance convenience and ease of use. Future studies might investigate the value of PDQ as a unique resource for information, as well as a replacement for traditional sources such as textbooks. By the conclusion of the study period and during the two weeks following, an additional eleven persons had learned to use PDQ (two nurses, one resident, three interns, four medical students, and one hematology-oncology fellow). These individuals were prompted mostly by seeing others use the database at the nursing station. They were all self-taught or trained by other staff members on the unit. This snowball phenomenon confirms other conclusions regarding the usefulness of this system in the clinical setting: busy clinical people must be strongly motivated to learn something new and need to perceive the learning as necessary to their practice. The peer or self-training of these eleven individuals also confirms the user-friendly characteristics of the PDQ system. In summary, PDQ was used more than once a day by the clinical staff on an oncology unit. Most users perceived the system to be useful for providing reliable background information or specific answers to patient care questions. Immediate, direct access to PDQ was considered convenient and saved time. Additional areas of study might include the evaluation of PDQ in oncology clinics or physicians' offices and the evaluation of other databases as clinical resources.
ACKNOWLEDGMENT The authors would like to acknowledge the staff and trainees on the 5 North Oncology Unit, University of Utah Hospital, for their interest and participation in the PDQ project.
2. HUBBARD SM, DEVITA VT. PDQ: an innovation in information dissemination linking cancer research and clinical practice. In: DeVita VT, Hellman S, Rosenberg SA, eds. Important advances in oncology, 1987. Philadelphia: Lippincott, 1987:263-77. 3. HUBBARD SM. When cancer information is needed PDQ. Hosp Pract [Off] 1987 Jun;22(10):84-90. 4. COVELL DG, UMAN GC, MANNING PR. Information needs in office practice: are they being met? Ann Intern Med 1985
Oct;103(4):596-9. 5. STINSON ER, MUELLER DA. Survey of health professionals' information habits and needs conducted through personal interviews. JAMA 1980 Jan 11;243(2):140-3. 6. STROSS JK, HARLAN WR. The dissemination of new medical information. JAMA 1979 Jun 15;241(24):2622-4. 7. KING DN. The contribution of hospital library information services to clinical care: a study in eight hospitals. Bull Med Libr Assoc 1987 Oct;75(4):291-301. 8. CIMPL K. Clinical medical librarianship: a review of the literature. Bull Med Libr Assoc 1985 Jan;73(1):21-8. 9. GREENBERG B, BATTISON S, KOLISCH M, LEREDU M. Evaluation of a clinical medical librarian program at the Yale Medical Library. Bull Med Libr Assoc 1978 Jul;66(3):31926. 10. HALBROOK B. Clinical librarian programs. Reflections on successes and failures. Clin Libr Q 1983 Sep;2(1):9-12. 11. NIPPERT CC. Online LATCH. Med Ref Serv Q 1985 Spring; 4(1):23-9. 12. ScURA G, DAVIDOFF F. Case-related use of the medical literature. JAMA 1981 Jan 2;245(1):50-2. 13. STEARNs NS, OTTOSON JM, HAITz C. Literature to go. Am J Nurs 1985 Oct;85(10):1161-2. 14. MATHESON NW, COOPER JAD. Academic information in the academic health sciences center, a role for the library in information management. J Med Educ 1982 Oct;57(10 part 2):1-93. 15. NIPPERT, op cit., 23-9. 16. GREENWALD P, SONDIK EJ, eds. Cancer control objectives for the nation: 1985-2000. Bethesda, MD: National Cancer Institute, 1986. 17. STROSS, Op cit., 2622-4. 18. COVELL, op cit., 596-9. 19. STINSON, op. cit., 140-3. 20. STROSS, op cit., 2622-4.
Received December 1988, accepted March 1989
REFERENCES 1. HUBBARD SM, HENNEY JE, DEVITA VT. A computer database for information on cancer treatment. N Engl J Med 1987 Feb 5;316(6):315-8.
22
Bull Med Libr Assoc
78(1) January 1990
Angier Associates 2360 North 57th Street Seattle, Washington 91803 Susan L. Beck, R.N. Clinical Nurse Specialist Harmon J. Eyre, M.D. Professor of Medicine, Division of Hematology-Oncology Utah Regional Cancer Center University of Utah Health Sciences Center Salt Lake City, Utah 84112
This pilot study examined the use of PDQ (Physician Data Query)-a user-friendly, full-text, cancer database-as a clinical information resource on an oncology unit. The twenty-nine participants included faculty, hematology-oncology fellows, residents, interns, medical students, pharmacists, and nursing staff. During the one-month study, PDQ was available twenty-four hours a day at the nursing station via a microcomputer. Participants were trained to use PDQ and allowed to search the database as prompted by clinical situations. The project evaluated the use of PDQ, as well as clinicians' perceptions of its usefulness. Results indicate that access to PDQ on an oncology unit provides an excellent educational and clinical resource. Fifty-one percent of the participants used PDQ an average of 2.4 times each. Heaviest users were medical trainees (78%), although 39% of nurses became users. Over half of the PDQ users reported that use of the database affected clinical care.
INTRODUCTION PDQ (Physician Data Query) is a user-friendly online database produced by the National Cancer Institute (NCI) to communicate current information on the diagnosis and treatment of cancer. Designed for use by physicians, it provides access to full-text, state-ofthe-art consensus statements from a board of recognized oncology experts, information on clinical trials, recent cancer literature, patient information, and a directory of oncology researchers and organizations [1-3]. Clinical personnel operate in a sophisticated, rapidly changing environment strongly influenced by research discoveries published in over 6,000 biomedical journals. Keeping current with the literature is a difficult and time-consuming process. Phy*
Formerly, head of Hope Fox Eccles Clinical Library, University of Utah Health Sciences Center, Salt Lake City, Utah 84112. Bull Med Libr Assoc 78(1) January 1990
sicians, nurses, and other allied health professionals often lack the time to pursue specific inquiries and frequently lack the skills to efficiently access the variety of resources available to them. In addition, the abundance of information in no way guarantees its quality or reliability. This paper presents the results of a pilot study for the University of Utah Medical School Project to examine the use of the PDQ system in the clinical setting. The overall project was supported by an award of 150 unbilled hours of PDQ system time from the National Cancer Institute. The University of Utah project explored the use of the PDQ system as a clinical and educational information resource in the inpatient setting. The study was designed to provide centralized access to the database on a twenty-four-hour basis and to identify which clinical staff and students used PDQ, and for what purposes. In addition, clinicians' perceptions of the system's usefulness in terms of day-to-day activities on the unit were investigated. 15
Angier et al.
REVIEW OF THE LITERATURE
Several studies have documented barriers to the use of published information in support of patient care activities [4-6]. Libraries have sought to bridge the gap between the need for patient care information and the difficulties of using traditional resources by developing clinical medical librarian programs. Clinical medical librarian programs are specialized services designed to provide an immediate response to case-related information needs and usually involve the assignment of a reference librarian to a patient care team. The librarian serves as a literature specialist on rounds or during other case conferences. In this manner, barriers to using traditional library services may be overcome by bringing the information relating to individual patients directly to clinicians. The effects of using the literature on patient care have only recently received systematic study [7]. The earliest studies evaluated clinical medical librarian programs and generally confirmed the convenience and time-saving benefits of these programs, as well as indicating a strong contribution to patient care [813].
Physicians, nurses, and other allied health professionals often lack the time to pursue specific inquiries and frequently lack the skills to efficiently access the variety of resources available to them. Clinical medical librarian programs are one method of providing access to the most current information. However, the large commitment of personnel time required to staff these programs limits their application in many clinical situations. An alternative to exclusive reliance on a human information specialist would be the location of user-friendly computerized information resources at the site of clinical care. The system would be supported by a literature specialist who would provide training, serve in a problem-solving capacity with individual users, and provide indepth literature searching backup as required. In 1982 Matheson and Cooper predicted that clinical medical librarian programs would stimulate the development of automated literature files accessed on terminals located in clinics, nursing stations, and physicians' offices [14]. As of May 1987 (the completion of the pilot study), the published literature contained no reports on the placement of a full-text or bibliographic database on a working inpatient unit. Nipper automated a variation of the clinical medical librarian program called LATCH (Literature Attached To CHarts) by using the hospital information system to relay requests for information to the library [15]. 16
Photocopies of articles were then attached to the relevant patient chart for use by all unit staff. The problem of wider, convenient access to information was
addressed by this system, but immediate delivery of the full text of the article is still an issue. NCI estimates that application of state-of-the-art treatment could reduce cancer mortality rates by 10% to 15% [16]. Stross and Harlan have identified several difficulties in the widespread dissemination of research discoveries through publication and continuing medical education to practicing physicians [17]. PDQ was developed to bridge the gap between research advances and practice applications and to serve as an easy-to-use resource representing the highest standards of care.
PDQ was developed to bridge the gap between research advances and practice applications and to serve as an easy-to-use resource representing the highest standards of care. The authors hypothesized that direct, immediate access to PDQ at the place where patient care activities occur would overcome many of the barriers to literature use encountered by clinical staff. It would also ensure the availability of information to an interdisciplinary staff regardless of work schedule. Because PDQ contains peer-reviewed information from the NCI, it serves as a high-quality resource with strong relevance to the patient care and educational activities on an oncology unit.
METHOD Design. The study was designed to evaluate the use and value of PDQ when it was made accessible to clinicians twenty-four hours a day for a month-long period. Participants were provided with the basic tools for using PDQ, including instruction on system commands and file content. Data were collected to measure system use and assess the value of PDQ to clinical activities. Primary interest was in identifying whether PDQ was used, how it was used, and by whom, as well as whether successfully located information was considered useful to patient care. Sample and setting. Participants included twentynine clinical staff and students engaged in patient care activities on a twenty-four-bed oncology unit at a university hospital. All staff and trainees assigned to the unit were notified of the opportunity and encouraged to participate voluntarily in the project. The study period extended from May 1 to May 31, 1987. Bull Med Libr Assoc
78(1) January 1990
The PDQ system
Procedure. Equipment to access PDQ was located at the nursing station on the unit and consisted of a Macintosh Plus with a twenty-megabyte hard disk, a 1200-baud modem, and an Imagewriter II printer. Red Ryder (version 9.4) telecommunications software was loaded onto the hard disk to eliminate the need for inserting a floppy disk for each terminal session. An automatic log-on procedure was programmed to reduce user involvement with complicated access and log-on protocols and diminish the technological aspects of using PDQ that did not relate directly to the system. For user assistance, the PDQ manual was located next to the terminal, along with a laminated user aid sheet that listed troubleshooting tips, the password, manual log-on techniques, and the library and home telephone numbers of the clinical librarian serving as the twenty-four-hour resource person. Training to use PDQ was provided by the clinical librarian and consisted of a thirty-minute session that covered the basics of file content, use of the menus, basic commands, logging on, and disconnecting. A sample search was conducted in the four files that make up the PDQ system: the Cancer Information file, the Protocol file, the Physicians file and the Organizations file. A total of twelve training sessions of one to four participants was held. At the completion of the training sessions, the clinical librarian withdrew from the unit to allow participants to search without interference but remained available if problems developed. Instruments. Three instruments developed by the investigator were used in the study. A short questionnaire was administered at the beginning of each inservice training session to collect baseline data on awareness of the PDQ system, as well as user experience with computer equipment and database searching. Responses to this survey were used to assess the relationship between previous experience and subsequent use of PDQ. A daily log sheet was designed to provide descriptive data on use of the system. The log sheet documented each terminal session according to who used the system, the purpose(s) (e.g., to increase knowledge, to support a specific clinical decision, for patient referral, to locate an expert consulting clinician/researcher, etc.), whether the database contained information addressing each purpose, and, finally, how much time elapsed during the search. The length of each terminal session was of interest for evaluating individual search time, as well as for accounting purposes. A structured interview with open-ended questions was administered to each participant to assess perceptions of the usefulness of PDQ in the clinical setting, expanding on the information collected at the terminal. The concept of usefulness focused on the Bull Med Libr Assoc 78(1) January 1990
Table 1 Frequency of PDQ use according to type of professional training Professional training
Total trained
PDQ use
A. Medical (MD) 1. Faculty/attending 2. Fellow 3. Resident 4. Intem 5. Medical student B. Nursing 1. MSN 2. BSN 3. RN 4. LPN
9
7 (78%) 0
1 1 1
C. Pharmacy
3 3 18 2 8 4 4 2
Total
29
1 1 2 3 7 (39%) 1 3 2 1
1(50%) 15(52%)
purpose prompting each use, as well as the ease of use, the sufficiency of knowledge contained in the database, the format of the information and the method of access. Participants who did not use PDQ during the study period were also interviewed to determine barriers to using the system. Nonusers were not prompted by any cues from the interviewer and explained their lack of participation in their own terms.
RESULTS In thirty-one days, the PDQ system was used thirtysix times for an average use of 1.16 times per day. Of the twenty-nine study participants, fifteen (52%) used the system. Each user averaged 2.4 uses of the system each. Table 1 shows the breakdown of users by clinical discipline. In the case of medical trainees and staff, 78% of those trained to use the system became users; 39% of nursing staff became users. Other study participants included two pharmacists assigned to the unit; one of them used the system. Of the fifteen individuals who used PDQ on the unit, eight were clinical staff and seven were students in training. Use of the system was higher by trainees (twenty-one sessions) as compared to staff (fifteen sessions). Table 2 Frequency of PDQ use according to prior experience and type of professional training Use of
Professional
Computer
training
experence
Medical (MD) Nursing
8 (6)* 15(7) 2 (1) 25 (14)
Pharmacy Total *
PDQ search experience intermediary awareness Searching 5 (4) 3(2) 0 (0) 8 (6)
4 (3) 6(2) 2 (1) 12 (6)
3 (2) 5 (3)
0 (0) 8 (5)
(N) = Became subsequent users.
17
Angier et al.
Table 4 Frequency and percent of positive perceptions of specific characteristics of PDQ usefulness (N = 15 users)
Table 3 Frequency of reasons for PDQ use and search results InformaReason 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
General information Drug information Treatment information Prognosis information Diagnosis information Protocol information Staging information Patient statement Other Referral information Total
Found Information Times information reported' adequate
13 3 2 2 2 1 1 1 1 0 26
11 1 1 2 1 1 1
11 1 1 2 1 1 1
0
0
1
1 n/a 19
n/a 19
tion neces-
sary2 11
3 2 2 2 1 1 1 1 n/a 24
1 Study participants may have reported more than one reason for searching
PDQ.
Information was considered "necessary" if user would have pursued the search via another source if PDQ had not been available or if their PDQ search was unsuccessful.
2
The study used approximately twenty hours of online search time: 12.4 hours for training purposes and 7.6 hours for searching PDQ by unit staff and students. On average, each search was 14.3 minutes long, with a median length of 10.5 minutes. In Table 2, the information obtained from the baseline questionnaire is related to subsequent PDQ use. An odds ratio test was applied to the data collected from the preliminary questionnaire to determine whether an association might exist between prior computer experience, end-user experience, previous use of a search intermediary or PDQ awareness prior to training, and subsequent use of the database. No significant association was found.
By far the greatest use was to find general background information on a specific diagnosis. Four individuals described their initial use as curiosity, although each of them was prompted by a real information need. PDQ users accessed the database for all available types of information (Table 3) except for referral purposes. By far the greatest use was to find general background information on a specific diagnosis. Four individuals described their initial use as curiosity, although each of them was prompted by a real information need. Three of those individuals went on to search the file again for additional reasons. Only the individual who was unable to find relevant information did not use the file again. 18
Characteristics 1. 2. 3. 4. 5. 6.
Easy to use Menu format useful Saved time Reliable access Display format useful Affected clinical management
Positive responses (%) 13(87%) 12(80%) 11 (73%) 11 (73%) 10(67%) 8(53%)
Users reported success finding information related to their query 73% of the time. In every case when information was successfully located, the information was judged to be adequate. All but two terminal sessions were prompted by an information need that was considered important enough for the user to have pursued it elsewhere had PDQ been unavailable or if their PDQ search had been unsuccessful. The positive responses of the fifteen PDQ users to questions relating to the usefulness of the database are summarized in Table 4. Over half felt that information retrieved from PDQ affected clinical management. In six of the eight positive responses, the users felt they approached individual patients in a generally more-informed way. Two individuals related specific clinical decisions that were affected by use of the file. Although most users of PDQ found information adequate to their needs, general comments during follow-up suggested additional areas for content expansion. Five nursing and medical staff users suggested adding general information on antineoplastic drugs, their side effects, and toxicity. One medical resident suggested that adding information on generic classes of drugs used for chemotherapy would be especially useful for patient care. The resident and the hematology-oncology fellow who participated in the study felt that the hematological diagnoses were too limited for their use. For example, they were unable to find information on myelodysplastic syndrome (preleukemia syndrome). Both nursing and medical participants were also interested in searching different diagnostic information in PDQ. They found the entry point of a specific diagnosis to the Cancer Information file limiting in the case of patients who were admitted with no diagnosis. Nursing staff suggested adding information on symptom management, as well as bedside care and assessment. Seventy-three percent of PDQ users reported that using the database saved them time. It was considered convenient since they did not have to leave the unit to visit the library, search through a personal library, or locate a knowledgeable colleague. Respondents who did not perceive that PDQ saved them time were Bull Med Libr Assoc 78(1) January 1990
The PDQ system
Table 5 Frequency of reasons for not using PDQ (N = 14 nonusers)
1. 2. 3. 4. 5. 6.
Table 6 Patterns of PDQ use by day and time (N = 37 uses1)
Reason
Times reported (%)t
Characteristic
Frequency
No time No opportunity2 No need Another user performed search3 Fear of using computer Not considered helpful
4(29%) 4(29%) 3 (21%) 2 (14%) 2 (14%) 1 (7%)
Day of the week Weekday (M-F) Weekend (Sa-Su) Time of the day 6:00 A.M.-noon 12:01 P.M.-6:00 P.M. 6:01 P.m-midnight 12:01 A.M.-6:00 A.M.
30 7 5 16 13 3
1 Participants may have reported more than one reason. 2 Defined as not scheduled to work on the unit for at least 50% of the study.
3In the case of two nurses, their queries were searched on PDQ by a third staff member.
frustrated by log-on problems, program loops while using the system, or lack of knowledge of the content limits of the database. In general, users found the menu system useful (80%). Users commented that menus made the system easy to use and eliminated the need to memorize searching commands. Two thirds of the users (67%) also found the format of the displays valuable. They had little trouble locating the specific information required within the sections of the file selected for display. Several users commented that printing the information for study in detail at a later time was an important advantage. Eleven of fifteen PDQ users also felt that telephone access of PDQ was reliable enough for use in the clinical setting. During the study, PDQ was accessed on a telephone line that was required periodically for unit business. In general, PDQ use did not conflict with unit business, but disconnects and log-on problems increased during peak business hours (10:00 A.M. to 4:00 P.M.). Fourteen study participants did not use PDQ during the month. The explanations given by nonusers during follow-up are summarized in Table 5. During the study period, four individuals felt that they had had no information need or that PDQ would not be helpful to them. Another four were extremely limited in their opportunity to use the file. Two were scheduled to work on other units for most of May. One person worked only one day per week, and one was on vacation for two weeks. Six study participants had originally planned to use PDQ: four felt hampered by lack of time while on duty; two were intimidated by having to use a computer. Two nursing staff were indirect users of PDQ. Their queries were searched by a third nurse who was enthusiastic about microcomputers, PDQ, and database searching. However, since none of the five terminal sessions they reported were logged on the daily sheets, these sessions were not included in the formal analysis. Bull Med Libr Assoc 78(1) January 1990
I Three PDQ users who logged terminal sessions were not part of the original study group; they were self-trained or trained by other staff. Those sessions are included in this table. Two study participants logged no specific sessions and could not be included in this table.
During follow-up interviews, users reported several problems using PDQ. The majority of problems (83%) concerned telecommunications, in particular the automatic log-on procedure. Comments described general difficulty with getting the Red Ryder program to work, but lack of user sophistication prevented a more specific diagnosis of the problem. A review of the daily log sheets indicated that there were only three completely unsuccessful log-ons reported (8%). However, additional problems were reported during the follow-up interviews, and several users stated that they did not record sessions in which they were unable to log-on. One study participant never logged any of his several attempts to access PDQ. A seventh user also had difficulty with the Red Ryder software: she was unable to initiate the print command successfully. Two users reported problems with line noise and disconnections. Only one individual reported equipment problems. The paper feed on the printer slipped frequently, resulting in a jam. Six users (40%) reported problems using the PDQ program software. One individual complained that response time was slow during one session, and a second found the displays too long. Four users reported problems with "program loops." After responding to instructions to select the number of an item to be printed or to select from a menu to continue a search, PDQ would return to the same menu or set of instructions and repeat the prompt. Three users who experienced this problem stated that disconnecting was the only way to break the loop; a fourth user reported that the program corrected itself after a number of repeat selections. Logging on after disconnecting corrected the problem in the case where instructions to select from the menu resulted in a loop. In the two cases, both in the Protocol file, the loops occurred a second time. Both users reported high frustration at apparently locating what they needed without being able to display the results. PDQ use occurred primarily on the weekdays (81%) 19
Angier et al. Figure 1 Frequency of PDQ use for each day of the week Total Number of Uses
May 4-31, 1987
9 T,
Su
M
Tu
Th
W
F
Day of Week
and between noon and midnight (78%) (Table 6). The weekly pattern (Figure 1) suggests that use of the system follows the same course as admissions to the unit. The greater number of admissions early in the week would prompt increased information needs over the course of the week as treatment progressed, which would taper off as patients were discharged for the weekend. DISCUSSION
PDQ was used primarily by medical trainees, but also by nursing and pharmacy staff. The highest use was by the third-year medical students who found the system to be an excellent and convenient educational tool for specific clinical situations. Both the attending faculty and the hematology-oncology fellow participating in the study stated that they would use the system regularly, though less often, and as a clinical, rather than educational resource. Use by medical personnel was an expected result of the study since the system was originally designed for physicians. However, use by nurses and pharmacists (all staff rather than students) confirms PDQ's potential as a clinical information resource for other patient care providers. The sufficiency of the knowledge base in this system needs to be studied in more detail. The average 20
use of PDQ in this study was 2.4 times per user. However, the reasons for successful multiple use may relate as much to an individual's growing understanding of the database content and its limits as to the actual sufficiency of knowledge for use in the clinical setting.
Use by nurses and pharmacists (all staff rather than students) confirms PDQ's potential as a clinical information resource for other patient care pro-
viders. There was no association between individuals who used PDQ during the study and prior computer experience, awareness of PDQ prior to training, previous use of an intermediary, or their own database searching experience. One explanation for this result at the University of Utah may be the high exposure of health sciences practitioners and students to automated systems. The Health Sciences Center at the University of Utah is a site for one of the National Library of Medicine's IAIMS (Integrated Academic Information Management System) projects. As a result of this project, hospital personnel and students Bull Med Libr Assoc 78(1) January 1990
The PDQ system
in training are exposed to a variety of electronic information systems, even if they do not use them regularly. Accessibility to a computerized resource may not in itself provide the motivation to use it at this location. In addition, the Spencer S. Eccles Health Sciences Library has been providing MEDLINE and other database searches through a librarian intermediary for over a decade. Use of an intermediary is a convenient method of collecting bibliographic information and may eliminate the need for an individual to search themselves. However, it would seem reasonable that clinicians or students who are motivated to learn to use a computer to search a database such as MEDLINE themselves are likely to be prompted to use a specialized electronic database such as PDQ. Awareness of PDQ prior to the study might also stimulate interest in trying the database. This was not supported by the data. However, the sample size of this study may have been too small to detect this relationship, and further study with a larger population is warranted. In addition, examination of possible associations between nonuse of PDQ and lack of previous experience with computers, PDQ awareness, prior use of an intermediary, or previous database searching experience may provide interesting perspectives on potential barriers to using the database. Another explanation for a result of no association between prior computer or database searching experience and use of PDQ may be that lack of experience is not a barrier to use. In this study, 87% of PDQ users found the system easy to use, and more than half of the total participants were comfortable enough to try it after one thirty-minute training session. A review of the daily log sheets showed that PDQ users accessed the Cancer Information file 6.5 times more often than the Protocol file, suggesting that background knowledge about a diagnosis was of most use to the participants of this study. This finding is consistent with the observation that the number of student terminal sessions was almost twice that of staff. The University of Utah Hospital is a tertiarycare teaching hospital in which several levels of students are assigned to the oncology unit every four to six weeks. For these individuals, cancer patient care is a new experience and offers a tremendous learning opportunity. Permanent clinical staff need background information as well, but may require it less frequently. Locally approved protocol information is readily available to students and staff in a notebook on the oncology unit. In general, this printed source is easy to consult. Since so many patients are admitted to specific protocols, the PDQ Protocol file would be used to search out a new protocol or consider another method of treatment in a patient not responding to the current one. Bull Med Libr Assoc 78(1) January 1990
The Physicians and Organizations files were not searched at all during the study period. This is not unexpected since the institution serves as a tertiarycare hospital and accepts more patients than it refers for cancer treatment. Evaluation of the use of these files might be more meaningful in the community hospital or office-based practice setting. Reasons reported by participants who did not use PDQ may provide valuable information for developing this database in particular and for implementing electronic services on an inpatient unit in general. The results of this study suggest that time and opportunity may serve as significant barriers to some individuals who originally intended to use the service. These results are similar to studies of more traditional use of the literature [18-20] and call for closer examination. Since the methods used in this study are biased to reporting use rather than nonuse, a more extensive investigation of nonusers might focus on determining whether these constraints also cover an underlying lack of interest or need, an insufficiency in the database, problems with equipment or software, fear of computers, or inadequate training in the use of electronic systems.
Busy clinical people must be strongly motivated to learn something new and need to perceive the learning as necessary to their practice. Problems encountered while using PDQ can only be identified and described by this pilot study. Several participants reported that they recorded only successful log-ons on the daily log sheets; thus, the usage analysis may actually be an underestimate of the use of PDQ. A closer examination of how far users who did not successfully log-on got in the process of accessing PDQ would provide valuable information for continuing to remove potential barriers for use. Program loops should be further documented. The frustration level of users who could not display the results of a search while apparently responding correctly to system prompts was high. This could prevent an individual from continuing to use PDQ. PDQ was perceived as useful by the participants in this study, and more than half of the PDQ users in the study reported that it affected clinical care. This is similar to the results of King, Scura, and Davidoff, and Stearns et al. In patient care examples related by two study participants, information from the database actually resulted in a specific management decision. Further study to evaluate more specifically the effect of PDQ on clinical decision making is warranted. More sophisticated criteria for defining the effects of an 21
Angier et al.
electronic reference service on cancer treatment need to be determined and measured. Reports that use of PDQ saves time is another significant indication that clinicians found the system useful. Eliminating log-on frustrations and program software loops will further enhance convenience and ease of use. Future studies might investigate the value of PDQ as a unique resource for information, as well as a replacement for traditional sources such as textbooks. By the conclusion of the study period and during the two weeks following, an additional eleven persons had learned to use PDQ (two nurses, one resident, three interns, four medical students, and one hematology-oncology fellow). These individuals were prompted mostly by seeing others use the database at the nursing station. They were all self-taught or trained by other staff members on the unit. This snowball phenomenon confirms other conclusions regarding the usefulness of this system in the clinical setting: busy clinical people must be strongly motivated to learn something new and need to perceive the learning as necessary to their practice. The peer or self-training of these eleven individuals also confirms the user-friendly characteristics of the PDQ system. In summary, PDQ was used more than once a day by the clinical staff on an oncology unit. Most users perceived the system to be useful for providing reliable background information or specific answers to patient care questions. Immediate, direct access to PDQ was considered convenient and saved time. Additional areas of study might include the evaluation of PDQ in oncology clinics or physicians' offices and the evaluation of other databases as clinical resources.
ACKNOWLEDGMENT The authors would like to acknowledge the staff and trainees on the 5 North Oncology Unit, University of Utah Hospital, for their interest and participation in the PDQ project.
2. HUBBARD SM, DEVITA VT. PDQ: an innovation in information dissemination linking cancer research and clinical practice. In: DeVita VT, Hellman S, Rosenberg SA, eds. Important advances in oncology, 1987. Philadelphia: Lippincott, 1987:263-77. 3. HUBBARD SM. When cancer information is needed PDQ. Hosp Pract [Off] 1987 Jun;22(10):84-90. 4. COVELL DG, UMAN GC, MANNING PR. Information needs in office practice: are they being met? Ann Intern Med 1985
Oct;103(4):596-9. 5. STINSON ER, MUELLER DA. Survey of health professionals' information habits and needs conducted through personal interviews. JAMA 1980 Jan 11;243(2):140-3. 6. STROSS JK, HARLAN WR. The dissemination of new medical information. JAMA 1979 Jun 15;241(24):2622-4. 7. KING DN. The contribution of hospital library information services to clinical care: a study in eight hospitals. Bull Med Libr Assoc 1987 Oct;75(4):291-301. 8. CIMPL K. Clinical medical librarianship: a review of the literature. Bull Med Libr Assoc 1985 Jan;73(1):21-8. 9. GREENBERG B, BATTISON S, KOLISCH M, LEREDU M. Evaluation of a clinical medical librarian program at the Yale Medical Library. Bull Med Libr Assoc 1978 Jul;66(3):31926. 10. HALBROOK B. Clinical librarian programs. Reflections on successes and failures. Clin Libr Q 1983 Sep;2(1):9-12. 11. NIPPERT CC. Online LATCH. Med Ref Serv Q 1985 Spring; 4(1):23-9. 12. ScURA G, DAVIDOFF F. Case-related use of the medical literature. JAMA 1981 Jan 2;245(1):50-2. 13. STEARNs NS, OTTOSON JM, HAITz C. Literature to go. Am J Nurs 1985 Oct;85(10):1161-2. 14. MATHESON NW, COOPER JAD. Academic information in the academic health sciences center, a role for the library in information management. J Med Educ 1982 Oct;57(10 part 2):1-93. 15. NIPPERT, op cit., 23-9. 16. GREENWALD P, SONDIK EJ, eds. Cancer control objectives for the nation: 1985-2000. Bethesda, MD: National Cancer Institute, 1986. 17. STROSS, Op cit., 2622-4. 18. COVELL, op cit., 596-9. 19. STINSON, op. cit., 140-3. 20. STROSS, op cit., 2622-4.
Received December 1988, accepted March 1989
REFERENCES 1. HUBBARD SM, HENNEY JE, DEVITA VT. A computer database for information on cancer treatment. N Engl J Med 1987 Feb 5;316(6):315-8.
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