CHAPTER 16

Point-of-Care and Clinical Decision Support Resources

SUSAN SWOGGER

One of the most vital and also most unique health sciences information needs is for accurate information at the point of care—at the bedside or examination table. A point-of-care (POC) resource is one intended for use by health-care practitioners in the clinic or hospital.

Point-of-care resources must provide reliable and current information both quickly and easily—immediacy and accuracy of information can literally be of life-or-death importance in medical situations. One oft-cited study reported that only 30 percent of physicians’ point-of-care information needs were being met in 1985, largely due to inadequacy of content and slowness of access to available information sources.1 In the period since that study was completed, this area has developed rapidly in response to opportunities provided by paradigm shifts to evidence-based medicine and to electronic information resources.

This chapter discusses the basic categories and qualities of POC resources, some of the reasons for their recent rise in prominence, and the reference librarian’s role in their use. See chapter 5 (Indexing, Abstracting, and Digital Database Resources) for a discussion of additional electronic resources that are of secondary but still important use at the point of care.

Evidence-Based Practice and Information Needs of Clinical Professionals

Clinicians and other health-care practitioners have always kept books and journals ready to assist with difficult consultations, so much so that a shelf of such materials is nearly always present in any artistic depiction of the professions, but two cultural shifts sparked a major change over the past decade—the growing use of the Internet to find every kind of information and the widespread adoption of the concept of evidence-based practice.

As discussed in chapter 5, the Internet provides access to vast amounts of information in a format that can be very quickly reviewed and synthesized, meaning that the majority of such resources are online. The need for both speed and a solid, broad evidence basis for clinical decision making has resulted in the rapid growth of specific POC resources intended to provide instant access to the required evidence. Clinicians will seek out information online, whether within a POC resource or outside it, and studies show that searches using POC resources are more likely to be both swift and correct than when performed with other Internet sources, PubMed, or academic databases.2^–3 As these other resources are likely to be both familiar and available to clinicians, online resources specifically intended for use at the point of care should be acquired and promoted.

A core concept in the design of most POC resources is the need to support evidence-based practice (EBP). The concepts of evidence-based practice and evidence-based medicine have spread rapidly through many fields of health and social care professions since the early 1990s, and they have become widely acknowledged as a dominant medical paradigm. The central tenet of EBP is that practitioners will “use the best evidence possible, i.e., the most appropriate information available, to make clinical decisions for individual patients”—or for nearly any other undertaking appropriate to a field.4

The “best evidence possible” is usually described as current evidence derived from the careful examination, evaluation, and synthesis of multiple peer-reviewed research studies. The Association of American Medical Colleges (AAMC) lists as an objective a requirement that medical students be “skillful,” defined in part as being able to understand the scientific basis and evidence of effectiveness for therapeutic actions, but this does not mean that every clinician will perform his or her own complete evaluation of the best evidence for every action taken.5 It does mean that every clinician is likely to need to refer to trustworthy sources that have reviewed the evidence while creating treatment protocols and recommendations.

Point-of-care resources are assumed to be such sources by most clinicians and are trusted as such—numerous studies show that recommendations from POC resources are likely to affect clinical decision making.6^–8 It is important that such influential resources are well chosen by the providing institution in order to meet this assumption and provide good, evidence-based information to clinical users. Recent political mandates have ensured that online POC resources will only rise in influence.

The HITECH Act and Clinical Decision Support Systems

The Health Information Technology for Economic and Clinical Health Act (HITECH Act), included as part of the American Recovery and Reinvestment Act of 2009, mandates that hospitals must have information technology that makes “meaningful use” of electronic medical records (EMRs) or face what are effectively reductions in Medicare and Medicaid payments in comparison to their peers.9 Although there is still some debate about the correct interpretation of meaningful use, the United States Department of Health and Human Services has stated that it must include the use of electronic tools for Clinical Decision Support (CDS), meaning that clinicians should be able to search and access an evidence-based clinical knowledge base while within individual patient health records.10

Though this phrase is often used to describe nearly any POC resource, by definition, a true Clinical Decision Support System (CDSS) is able to accept and return a search based on inputted patient data for an individual case and is intended to aid in diagnosis and decision making rather than act strictly as a reference tool.11 A CDSS that meets the aims of the HITECH Act must be fully integrated into an EMR system. While many specialty CDSSs exist, those capable of EMR integration most commonly support multiple clinical specialties, often with a focus on diseases, conditions, and pharmaceuticals. This is an area of rapid development and change and is likely to become even more prominent in the near future.

Many POC publishers and EMR developers either already offer or have begun to develop means to integrate POC resources and EMR systems. Most of these are at varying stages of adopting the HL7 infobutton standard, developed to standardize and thus facilitate the integration between POC and EMR systems.12 The HL7 standard requires that an EMR interact with a POC resource to produce “infobuttons” specific to an individual record that may be clicked to pull relevant information from the POC knowledge base.13 This will permit a much greater number of resources to act as HITECH CDSS than is currently the case.

Librarians and Point-of-Care Resources

Although on the surface a resource designed for easy and intuitive usability that is likely to be integrated within an EMR may not display a need for the assistance of a librarian, there are a number of reasons why reference librarians should be knowledgeable about such resources. It is common for the library to be involved with the selection of such resources when subscribed institutionally, thus requiring knowledge of a wide variety of resources. Some hospitals support individual subscriptions to specialty resources for clinicians involved in particular areas of practice, which may fall to the librarian to manage and support. Once such a resource is chosen and in place, regardless of whether it is available institution-wide or is institutionally supported for individual users, there must be continuing and sustained librarian involvement in a number of roles.

Librarians usually serve as the first point of contact for most hospital and student users who need assistance with any online resource and will receive questions requiring a good understanding of both their content and use—POC resources are no different in this respect. POC resources are also by design somewhat superficial; if a clinician encounters an unusual or confusing case, he or she may not be able to provide an adequate answer. If a librarian is to most effectively assist in going beyond the POC resource, he or she must have a good understanding of both its limitations and what the clinician is likely to have already found on his or her own. This is true for both academic and hospital librarians—while POC resources are designed to meet the needs of clinicians in practice, they are also popular with student users. Health sciences students who have them available often find them useful as a starting point in understanding new topics—although they may need some assistance in realizing that they are best used as starting points and not as complete coverage for a new learner.

Librarians are often expected to provide or arrange training for the use of POC resources, just as with other online resources. This could include anything from arranging for the visit of a vendor-provided trainer, offering individual training, teaching classes to new cohorts of residents, or creating detailed online tutorials. Each of these options requires close and current knowledge of each resource. If a POC resource is available to every user on a campus IP range, it is also possible that campus users outside of the health sciences may encounter them and have questions, possibly requiring the health sciences librarian to assist. For example, many people have questions about prescription medications: Kinesiology students or athletes may seek out practical orthopedic information, and law students may try to find information to understand malpractice issues.

Hospital librarians may also find themselves supporting clinicians in other ways. Many may go along on hospital Grand Rounds, or the presentation of patients to groups of clinicians and clinicians in training, to provide expert searching assistance. In some cases, they may be responsible for managing the Continuing Medical Education (CME) functions provided by many POC resources. Many POC resources offer an option for recording and reporting CME or Continuing Education (CE) credits for clinicians who create personal logins for the resource and perform searches. The American Medical Association (AMA) and other professional associations offer some CME credits for recorded searches, which can be very useful for clinicians These resources typically require a core administrator—who may be a librarian or require a librarian’s support—in order to manage and track credits for all of the users of a particular resource.

Qualities and Formats of Point-of-Care Resources

As discussed previously, POC resources have several important qualities that are universally important because of their specific purpose, regardless of topic coverage. Their clinical content must be evidence-based and relevant to practice. Many tout their own skill at the evaluation of evidence and creation of reviews and recommendations—their process should be transparent and performed by respected reviewers. They must be regularly and frequently updated. They must be easy to search, understandable to read, swift to use, and free of unnecessary clutter. Finally, they must be available readily and in a format that is possible to use in the necessary location, which may range from a hospital lab to a clinical examination table to an ICU bedside.

Format can have a strong effect on whether a particular POC resource displays these qualities. It is also common for one POC resource to be available in multiple formats to meet different requirements, sometimes with unique content within each different manifestation depending on relevancy to intended uses. In this situation, it is not unlikely that a library or hospital may have multiple subscriptions to different forms of the same resource. For example, the author’s home library once had access to a particular drug database in four different formats: It provided the hospital formulary, separately provided the drug content within a multi-specialty clinical POC database, was subscribed as an independent academic database, and was made available as a mobile application to a small group of faculty.

The variety of formats is changing rapidly and it is likely that this list will have been augmented by the time it is read; however, the following are the current most prominent options.

Individual Print or Electronic Books

Typically available in both print and downloadable e-book formats, these often have a long history of multiple editions. Most are in outline or handbook format and serve as quick reference for such topics as disorders and conditions, diagnostic algorithms, and prescriber’s guides. This chapter will not further address these titles, but the subscription health sciences book review service Doody’s Core Titles is an excellent source of further information (available at http://www.doody.com/​dct/).14

Note: These are distinct from “enhanced” e-books databases, which may have begun their histories as print books but are now available as databases that include a large amount of additional multimedia or interactive content to supplement the original text.

Stand-Alone or Clinical Decision Support System Databases

These are the resources currently most and least likely to be used by health sciences librarians, as this category includes both POC databases and CDSS resources fully integrated into hospital EMRs. They include content such as but not limited to original monographs, image libraries, special journal article collections, decision trees, clinical books, vaccination schedules, calculators, streaming procedural videos, prescription guides, interaction checkers, and more. Some draw content from multiple publishers; others focus on content from one publisher. Some address multiple clinical specialties; others include just one. They can typically (barring some CDSS) be used independently of other resources even if capable of EMR integration, and are subscribed by academic as often as hospital libraries.

Note: Many of these databases may be searched or used with other databases both academic and clinical when subscribed on the same platform or when a partner agreement exists; this may be customized to best suit the needs of an institution. For example, subscribers of EBSCO’s Dynamed may also subscribe to and integrate content from several others of its many POC databases and from the MEDLINE portion of PubMed and/​or choose to integrate content from select other providers including Lexicomp and ZynxHealth. Each of these is further described below.

Note: Hospitals are highly likely to also have subscriptions to formulary databases containing prescribing and pricing information about drugs used specifically by the hospital or supported by particular insurance plans. It is unlikely that librarians will use or have access to these, but they may provide support for resources used by those who manage the formulary. It is also fairly common to have separate library subscriptions to the same databases used for the hospital formulary, albeit in a different format. It is important to be aware of any such overlap, as there may be confusion when discussing said resources with users or billing managers who are familiar with both but do not realize that they are separate subscriptions or installations.

Mobile Applications

Mobile resources are becoming increasingly widely used by clinicians and health sciences students just as is true of the general population. While the majority of these resources require a constant WiFi connection, some permit users to download significant or all content for use offline. This is highly desirable for many groups of users—students away on rotation or doing research, clinicians providing care outside of the hospital, any users dealing with very restrictive limitations on Internet use (common in hospitals), any users in older buildings with poor WiFi connections. Most of this type of downloaded content requires the user to maintain an affiliation with the subscribing institution, which may be managed manually by requiring individual annual renewals or automatically by using the resource via WiFi connection within the hospital or university IP range.

There are presently four mobile access types of major relevance to health sciences libraries:

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