Overview
The information overload of physicians is getting worse,
according to a U.S. Department of Health and Human Services
(HHS) study conducted by the Lewin Group, which examined the
information needs of physicians. The study synthesizes the
literature on this topic, analyzes the opportunities and problems
posed by electronic information sources, and contains the results
of focus groups looking at these issues from the standpoint of
practicing physicians. The effort has produced an electronic
database of more than 200 articles researched for the study. The
full report, "Information To Guide Physician Practice,"
with a 4-disk database, entitled the "Physician
Information Literature Database," is available from the
National Technical Information Service (NTIS), Springfield, VA
22161, telephone (703) 605-6000 or 800-553-6847. Order Accession Number
PB97-500250, $50.00 U.S.
Summary
With the growing scope and complexity of medical information,
physicians are finding it increasingly difficult to stay abreast
of current medical knowledge. This growth in physician-targeted
medical information is evident in the proliferation of
subspecialty journals, the growing presence of clinical-economic
studies, and the escalating marketing efforts of a range of
actors. Policymakers and managed care providers have entered the
fray, vying to affect physician practice with an expanding array
of clinical guidelines, profiling, and utilization review.
The rapidly increasing availability of information has
coincided with fundamental change in the structure and delivery
of care. The many facets of health care integration include the
growth of managed care, hospital mergers, formation of physician
hospital organizations, and the expanding presence of corporate
medicine. Access to medical information and dissemination of
findings is central to the management of costs and clinical
outcomes. Integration has also heightened the prospects for
health data integration and the electronic medical record.
The medical community also stands poised for a major
revolution in the way medical information is organized and
disseminated. Electronic sources of information (e.g., medical
outcomes software, proprietary access services, the Internet, and
CD-ROM educational materials) are growing in number and
popularity. Many physicians' offices are automating, in much the
same way that hospitals and other medical institutions began to
automate in the 1980s. Electronic information sources promise
administrative simplification and ease of access to information,
although, in many of their current forms, they also contribute to
physicians' "information overload."
To understand this dynamic environment better, the HHS Office of the Assistant
Secretary for Planning and Evaluation (ASPE), in
collaboration with the Agency for Health Care Policy and Research
(AHCPR), contracted with The Lewin Group to study the sources of
physician information, the screens that physicians use to
determine which information is most valuable, and the
implementation of information in a practice environment. The
study included three phases:
Literature Synthesis and Database Retrieval System
More than 200 articles from literature relating to the
information environment faced by physicians were reviewed, major
themes were synthesized, and an interactive database was created
to allow researchers to access this literature easily.
Characterization of the Online Resources for Physicians
Because there was little literature characterizing online
electronic sources of information (e.g., the Internet), a focused
study of Online Medical Networked Information (OMNI) for
physicians was completed.
Lessons from Physician Focus Groups
Given the rapidly changing environment, it was particularly
important to test the findings in the field. Three focus groups
were conducted: attending physicians in an academic medical
center; a small rural practice; and a group of resident
physicians.
Following are summaries of each of these areas, and some of
the lessons that emerge from the study, highlighting examples
from the focus groups.
Literature Synthesis and Retrieval System
The literature component of this study includes a targeted
review and analysis of the role of information in shaping
physician practice. The focus of the literature review is the
practical use of information by physicians, rather than the
theoretical underpinnings of information diffusion. The
literature review includes recent scientific and non-scientific
literature, as well as lay sources, including newspapers and
newsletters.
The first phase in conducting the literature review was to
create a structure within which the literature could be analyzed.
An analytic framework for organizing the literature was
developed, with three main categories:
Sources of information available to physicians:
literature that describes or evaluates sources of medical
information used by physicians in their professional practices.
Sources of information include: journals; guidelines; marketing;
Internet; informal information exchange; integrated information
systems; decision support systems; continuing medical education;
patient satisfaction; peer review/profiling; and utilization
review.
Determinants of physician use of information:
literature on factors affecting both the decision to use an
information source and how the source is used. Determinants of
information use include: physician age; physician training;
physician specialty; physician practice location; legal
environment; financial environment; administrative environment;
source type; potential use; complexity/presentation; and
voluntary/mandatory access.
Results of information use on physician behavior:
literature that discusses the effects of information use on
physician behavior and practice patterns. Results of information
use are: physician change in service provision; physician change
in guideline compliance; patient mortality; patient morbidity;
patient quality of life; and patient behavior.
Electronic searching of major information collections and
services was used to identify relevant articles for inclusion in
the literature review. The search was limited to articles
published from January 1, 1991, through November 1, 1995, since
an annotated bibliography by the Agency for Health Care Policy
and Research analyzed the literature prior to 1991 (Information
Dissemination to Health Care Practitioners and Policymakers),
AHCPR Pub. No. 92-0030. The search included information
collections containing scientific and nonscientific literature,
as well as collections containing lay sources, including
newspapers and newsletters.
A graphical
summary (39 KB) of the article selection process is provided.
Literature Review Findings
The literature on sources of information shows that physicians
are receiving information from more varied sources than ever
before. Journals continue to be an important and authoritative
source of information, but suffer from speed of use and
accessibility limitations. Electronic sources are often available
more rapidly, but are currently not considered as dependable as
journals. Although the field of medical informatics has advanced
substantially over the last decade, the integration of patient
information, clinical guidelines, expert medical systems, and
administrative information is a critical concept still in its
infancy.
The literature on determinants of information usage shows that
physicians judge the information they review on the basis of a
number of criteria. The imprimatur of a good journal is critical
for credibility of new findings. Indeed, physician involvement in
producing the source and the peer review process are often key
ingredients for a source's credibility. Physicians are more
likely to act on information if there is a monetary incentive
involved, and to screen out information from questionable
sources, highly complex data, and voluntary guidelines. The way a
physician obtains and evaluates information is also influenced by
a number of environmental factors, including specialty, age, and
practice location.
The literature on use of information contains many examples of
instances in which dissemination of clinical information (e.g.,
from clinical practice guidelines, integrated information
systems, or physician education programs) has led to changes in
physician practice. Integrated sources have great potential to
help physicians cope with information overload, and have been
shown to improve compliance with guidelines and reduce adverse
events. However, such success stories are usually focused on
specific examples, and there are few broader studies that cover
multiple information interventions. In addition, the literature
lacks systematic and representative studies of many common means
of delivering information to physicians, such as journals,
marketing, patient assessments, and information exchange.
The Database
To facilitate the literature analysis and the development of
hypotheses for the focus groups, an interactive database was
created, containing structured summaries and citation information
of the reviewed articles. With an electronic database, focused
searches can be conducted to explore the degree to which the
literature addresses important topics related to the impact of
information on physician practice.
The database was organized using the study framework
described. The first screen of the database contains citation
information, the study methodology, and designation of the broad
framework category (i.e., sources, determinants, results). The
second set of screens indicates the subcategories into which the
article is classified. The final screen contains a summary of the
article, structured by goals, methods, results, and conclusions.
Query commands are constructed that allow a user to search the
database from a variety of organizational perspectives. Titles
can be searched for key words and text strings. Text searching of
the structured summaries is also possible. In addition, articles
may be grouped by category, subcategory, author, reference, or
study methodology.
Study of Online Medical Networked Information
This phase consisted of a special study detailing new online
sources of information in shaping physician practice. Interest in
electronic information sources has grown rapidly, fueled by the
promise of quick and user-friendly access to large volumes of
information.
Barriers to the use of online information, including lack of
time to access online information, lack of training and
understanding of computer technology, limited access to hardware
and software, and concerns about the quality and completeness of
information in "non-traditional" sources have slowed
progress towards this vision. Given these barriers, a growing
body of articles in the trade press has emerged to describe and
explain electronic information sources.
Electronic medical information can be placed into three
categories: static sources such as informational CD-ROMs and
diagnosis support software; clinical information systems run by
managed care organizations, hospitals, and physician practices;
and online networked information accessible via personal
computers and positioned for use by a large audience. The last
category, Online Medical Networked Information (OMNI), is the
primary focus of this work. Others have recently reviewed the
first two areas as well as the field of telemedicine.
OMNI can typically be found in commercial online services and
on the Internet. OMNI sources have made many new types of
information more readily available to physicians. The scope of
this information is broad, including new versions of traditional
media sources, such as journal articles and clinical practice
guidelines in electronic format, as well as more innovative
resources, such as a "virtual hospital" with
"virtual patients" for training and education.
Because the published literature offers no comprehensive
listing of OMNI sources, the World Wide Web (WWW) was used to
locate sources as inputs into a taxonomy
of OMNI chart (50 KB). Five major commercial WWW subject
guides and their associated search engines were first used to
identify home pages of important OMNI sources. These search
engines scan text on the Internet similar to the way MEDLINE
scans abstracts in the medical literature.
The primary distinction in the taxonomy is between Informational and Interactive sources. Informational sources are
sites whose primary approach is to present information on a given
topic. Interactive sources are sites whose primary
function is to facilitate the exchange of information among
users, often in the form of real-time dialogue. Individuals can
log on and revise their own "informational" Web sites,
and an informational OMNI source can become interactive through
links to other sites.
Focus Groups
Three focus groups were conducted to test the findings from
the literature review. Primary observations of the information
environment faced by physicians are particularly important in
light of the dramatic increase in the volume of information,
rapid changes in the structure of practice, and advances in the
technology infrastructure. The three focus groups were designed
to gather information on distinct groups of physicians with
different needs and access to different levels of resources.
Although limited in scope and size, the focus groups played an
important role in assessing the validity and the completeness of
the analysis of physician information use. Three focus group
meetings were conducted: one centered on attending physicians in
a large academic medical center, one centered on residents, and
one centered on a rural health center. Each focus group was
composed of 4-8 providers.
To facilitate the focus groups, a Focus Group Assessment Tool
was developed that addressed a full range of questions necessary
to characterize the actual information environment in practice.
The Assessment Tool allowed gathering of information about the
types of information physicians use and how this information is
utilized in different physician practice settings prior to each
focus group.
Highlights from Focus Groups
Patient satisfaction is an indication of medical quality...
Patient satisfaction information was described as essentially
non-clinical by the doctors in the academic medical focus group:
the appointment took place on time; the paperwork was minimal;
they had no trouble parking; both providers and administrators
treated the patient and his family pleasantly. Physicians
considered patient satisfaction information to be critical
information from a business perspective, noting that patients who
are not satisfied may go to another doctor and/or hospital.
Furthermore, they gave examples of hospital public relations
materials in which patient satisfaction information was used as
advertising to payers and health plans. In contrast, rural health
providers clearly viewed patient satisfaction as a critical input
to quality, noting that satisfied patients are more likely to
follow providers' recommendations.
Keeping up with the news media is very important for
understanding patients' concerns...
A rural physician in the focus group had several patients tell
her that they didn't want to take their medication for high blood
pressure. She realized that they were frightened by recent news
reports that the medication could have adverse effects. Once she
understood the basis of their concerns, she was able to explain
why the medication was safe. The provider emphasized that
addressing the patients' concerns was essential, because
otherwise they would stop taking their medication.
Perceived value of guidelines varies...
One physician in the focus group noted the high quality and
value of national guidelines in hematology, citing both content
and format. He distributes the guidelines and instructs his
residents and medical students to keep the guidelines in their
pockets whenever they are in the hospital. By contrast, a
pediatrician in the group criticized both the availability and
usefulness of national guidelines in pediatrics. She noted that
the dearth of national guidelines for pediatrics and the general
nature of those that exist do not enable her to make effective
use of them in practice.
Interacting with other providers is difficult in a rural
environment...
A physician in the rural focus group noted that he was one of
only six doctors serving a county of roughly 25,000 people. The
relative isolation of providers makes it difficult to have access
to colleagues for consults, informal exchange of information, and
grand rounds at his 20-bed hospital. He had explored getting
video tapes of grand rounds from other hospitals, but with
minimal success. Similarly, he noted that telephone consults were
logistically difficult—he sees many patients daily, and
coordinating times to talk to other doctors is very problematic.
Rural physicians in the focus group relied on continuing medical
education (CME) and other conferences as a primary source of
information. Several of the rural providers indicated that they
learn about new treatments and technologies at these conferences.
Furthermore, one rural provider indicated that she uses CME
courses to make contacts with specialists she can contact later
for consultations. She also uses CME courses to identify the most
important recently published articles that she should read.
When patients surf the Web...
An attending physician in an academic medical center described
a situation in which a patient told the doctor that his
recommendations conflicted with information in an article that
had been discussed in a patients' group on the Web. The doctor
was not familiar with what turned out to be a scientifically
questionable article that had been disseminated in cyberspace—a
domain where peer review is the rare exception. The patient did
not consider the doctor to be credible because he was "not
current" with the real-time information available on the
Web. The doctor had to find the article, read it, and then
explain its flaws to the patient before the patient would accept
the doctor's recommendations.
Currently available electronic sources have little to offer
residents...
Residents indicated that information systems and the Internet
were not effective sources of information for their clinical
practice. Residents indicated that when they need information to
treat a specific patient or handle a particular clinical problem,
they need the information immediately. They do not have time to
look up information on the World Wide Web, or to use the limited
CD-ROM or other information systems to which they have access.
This situation was noted as unfortunate, given that the residents
had spent considerable time in medical school using electronic
sources, and were positive about their potential as information
tools.
Critical use of high authority sources...
One physician in internal medicine related a grand rounds
discussion of an article in a leading journal regarding the use
of fish oil to treat nephropathy. Physicians in the room were
asked to raise their hands if, after reading the article, they
would prescribe fish oil to their patients with nephropathy. All
of the residents and none of the attending physicians raised
their hands. Then one of the senior attending physicians pointed
out numerous problems with the article, and gray areas as to how
it could be applied in various clinical situations. After this
discussion, the residents acknowledged that they had been reading
the article naively.
Electronic sources of the future offer important
improvements on CME...
A surgeon in one of the focus groups noted that CME in surgery
is only moderately useful because it is very difficult in a
classroom or lecture setting to convey new surgical techniques.
He noted that the real-time transmission of audio and video
across the Web would enable surgeons to demonstrate a technique
in the operating room to a national audience.
Conclusions
The information environment faced by physicians has undergone
a radical transformation over the past decade, with the emergence
of profiling, guidelines, online information systems, and many
other novel sources of information. This transformation has
occurred against a backdrop of changes in the health care
delivery system, as providers have integrated, managed care has
strengthened, and public programs have become more sensitive to
costs.
The study shows that the current environment is rich with
diversity, yet highly chaotic. There is more information
available, in more formats than ever before, competing for the
limited time that physicians have to keep abreast of changes in
the medical world. The electronic information age is slowly
transforming this landscape, but has not yet delivered tools that
can reliably and sensibly alleviate the information overload
faced by many physicians.
As a result, physicians must screen information sources
aggressively to determine what information will be allowed to
guide their practices. This screening process appears to depend
significantly on characteristics of the physician, the
financial/legal environment in which he or she practices, and,
significantly, on the source and type of information that is
being provided. Consequently, it appears that much of the
information being distributed is not being fully absorbed by
physicians.
The health care environment poses very serious challenges to
public agencies, managed care organizations, and others wishing
to influence physician behavior through the dissemination of
information. To capture the attention of physicians effectively
without using payment as leverage, information must be timely,
relevant, authoritative, and easily accessible. These imperatives
will become more stringent as major medical journals and
pharmaceutical companies develop highly accessible and attractive
sources of information for physicians.
Special Issues Affecting Rural Providers
All three phases of the study showed that physicians face
different and particularly difficult problems in accessing
information. Colleague consultation and informal exchange of
data, a principle source of information for physicians in
academic medical centers, is simply not available to many rural
physicians. Practitioners in the focus group noted that the rapid
telephone consultation programs initiated in some States are
highly useful.
Access to computers, satellite technology, and
telecommunication links holds particular promise for isolated
rural providers. Current technologies described in the literature
already provide medical education through satellite links, and,
in some instances, access to telemedicine services from major
metropolitan areas. Virtually all rural providers agree, however,
that they generally lack access to current technology because of
limited funds, and that public health could be better served
through expanded access to health information.
Use of Online Resources in Practice
The study of online resources shows a wealth of readily
accessible data and other information. Physicians can interact
with colleagues from a distance and access highly specialized
physicians in a variety of clinical areas. It is likely that
physicians in certain types of practices, for example physicians
in academic and other research settings, have greater access to
and realize greater benefits from the types of information
currently available online. However, little data are available to
indicate usage patterns, or physicians' perceptions of the
greatest benefits of online service.
The rapid growth of medical information on the World Wide Web
and through online services such as America Online and CompuServe
presents challenges and opportunities for physician-patient
relationships. The positive aspect of this development is that
patients may have access to information that was formerly only
accessible to physicians, such as interactive searches of medical
journals and conference proceedings. The negative aspect is that
quality control is virtually absent on these online information
venues, and patients may be misled by incorrect or incomplete
information. In addition, patient knowledge cannot substitute for
physician judgment and interpretation of information, which is
often based on a range of factors that are not in the literature.
This study suggests that the primary barrier to the use of
current online information sources is that existing sources are
not of sufficient value to justify the time needed to access
them. Physicians are, typically, exceedingly busy, and current
online sources do not save them time. To the contrary, they are
often difficult to navigate and not directly relevant to
physicians' clinical concerns. Future development of software
solutions to organize and streamline information holds promise
for addressing these issues.
There are also a number of other barriers to use of online
information sources, including lack of easy access and a fear of
computers. Although most academic medical centers and large staff
model health maintenance organizations (HMOs) are connected
through Local Area Networks and high-speed telecommunications
lines, physicians often lack this type of access in their
offices.
Other potential barriers include concerns about information
quality and security. There are no formal quality control
measures for OMNI sources. To a certain extent, concerns about
quality and security relate to the interactive nature of OMNI,
e.g., preventing individuals or organizations from manipulating
data or presenting biased information. Similarly, while
electronic "consultation" with other physicians is
valuable, it is often difficult to assess the source and quality
of information received in this way.
It is very difficult to ascertain how many physicians are
accessing the wealth of information available online, and how
users are assimilating the information they receive. User
statistics are generally poorly documented and many online
sources are posted with no mechanism for collecting such
information. Moreover, while it is likely that some research on
the physician market for online services has been conducted by
companies interested in pursuing this market, those data are not
publicly available. The issue is further complicated by the
dynamic nature of the market, as data become obsolete shortly
after they are collected and analyzed.
The Future of Clinical Information for Physicians
Understanding physicians' decisionmaking process regarding
information use becomes a crucial part of determining how to best
influence physician practice. With the growing emphasis on
medical costs and outcomes, providers, payers, administrators,
manufacturers, and policymakers must all be concerned with
identifying solutions for bridging the gap between production and
consumption of medical information.
As electronic information sources play an increasingly
important role in the "information age," a critical
area of exploration is whether focused development of newly
emerging electronic sources constitute one such solution. An
explosion of interest in online delivery of services from vendors
of information has already been seen. Major medical journals,
such as the Annals of Internal Medicine, The New
England Journal of Medicine, and The Journal of the
American Medical Association have also begun to explore
provision of information online. Such trends point to an
increased role for online services, assuming that limitations can
be addressed. As these services become better organized and
develop more formal quality control measures, expanded use by
physicians is likely to follow.
It is not difficult to fantasize about the future of online
information. Possible innovations include: standardized, fully
electronic medical records; interactive medical textbooks that
are updated instantaneously with the results of new medical
studies; instant, online access to well-organized information on
pharmaceutical products as soon as they are approved by the U.S.
Food and Drug Administration (FDA); and localized registries of
antibiotic sensitivities in clinical situations where resistance
is an issue. All of these ideas are in the realm of possibility,
and would help physicians to practice more effective and perhaps
more cost-effective medicine.
AHCPR Publication No. 97-N006
Current as of November 1996
Internet Citation:
Information To Guide Physician Practice: Overview. AHCPR Publication No. 97-N006, November 1996. Agency for Health Care Policy and Research, Rockville, MD. http://www.ahrq.gov/research/physprac.htm
540 Gaither Road Rockville, MD 20850