Role in evidence-based practice
Lindsay M. Boyce; Donna S. Gibson; Konstantina Matsoukas Memorial Sloan Kettering Cancer Center, New York, NY, United States
Abstract
The role of the research informationist in advancing evidence-based practice is discussed within the context of a comprehensive cancer center setting. The Clinical Medical Librarian Program and the Systematic Review Service represent two key library services that illustrate and support how the informationist contributes to the evolving field of evidence-based health care.
Keywords
Clinical medical librarian; Evidence-based practice; Health care; Informationist; Librarian; Memorial Sloan Kettering Cancer Center; Systematic review.
The Memorial Sloan Kettering (MSK) Cancer Center Library (https://library.mskcc.org) supports one of the oldest cancer centers in the country committed to exceptional patient care, leading-edge research, and outstanding educational programs. In 1960, the hospital merged with the Sloan Kettering Institute to form the organization that is in existence today. The institution was one of the first to receive the National Cancer Institute’s Comprehensive Cancer Center designation with state-of-the-art research being conducted in tandem with quality patient care (National Cancer Institute, 2012). The mission of the library is closely aligned with the mission of the center. As information professionals, staff proactively partner with library users by delivering innovative services and targeted published content in support of quality patient care, research excellence, and ongoing learning, for the progressive control and cure of cancer.
The types of user services offered by a research library play a key role in how users perceive, engage, and collaborate with their librarians. Each library needs to understand what matters to their constituents in order to develop and implement relevant services that will have a positive and fruitful impact on their users’ work activities, and ultimately contribute to the high level goals of the organization. This is and will always be a continuous process.
The MSK Library offers a myriad of services (https://library.mskcc.org/services) and this chapter will focus on two that directly support evidence-based practice (EBP)—the Clinical Medical Librarian (CML) Program and the Systematic Review Service.
7.1 Definition of EBP in a healthcare setting
The most commonly cited definition of EBP comes from Dr. David Sackett, in his 1996 letter in BMJ on what evidence-based medicine is and is not. In the letter, he described EBP as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients…integrating individual clinical expertise with the best available external clinical expertise from systematic research” (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). Since then, the definition has broadened to a philosophy of clinical practice that integrates the critical appraisal and synthesis of the best evidence, clinical expertise and local best practices, and patient preferences (Melnyk, Fineout-Overholt, Gallagher-Ford, & Stillwell, 2011).
The process of EBP must start with a desire to inquire and question practices. This involves health professionals’ challenging practices and asking questions about their patients’ care. Only when this cultural paradigm is implemented at the institutional level can EBP be fully accepted as the standard of care.
EBP is a series of steps that starts with identifying gaps in clinical knowledge and asking questions directed toward those gaps, to search for and collect the best evidence to fill those gaps, critically appraise the evidence to determine its quality and applicability, and finally integrate the best evidence into one’s clinical decision-making. The outcomes of these clinical decision changes must then be evaluated and disseminated to the broader institution and medical community.
Research informationists can, and do, play a vital role in advancing EBP activities within their institutions by offering services that support this doctrine, sharing their expertise in searching and evaluating the published literature, and providing access to resources that support learning how to apply EBP. They should take a leadership role in creating tailored online tutorials, information portals, and conducting EBP workshops specific to the research needs of their user community. The ongoing objective is to “continuously” look for opportunities to foster best practices in how to identify and evaluate information and published research.
Information professionals have been involved with clinical medical librarianship for decades where their role has expanded through EBP—they have moved beyond just identifying the literature to teaching search strategy development and critical appraisal of research evidence. The two services that will be highlighted in this chapter will touch on the MSK customized CML Program, a well-established service, and a fairly recent service that provides systematic review publication support.
7.2 MSK CML program
In 1999, the MSK Library launched its CML program by collaborating with three of the institution’s services: Gynecology Service, Gastric and Mixed Tumor Service, and the Department of Psychiatry and Behavioral Sciences. This was a way to provide added value, integrate with a team, and showcase the expertise and research skills of the reference staff. By partnering with these specific groups, the intent was to deliver high-touch and adapted services based on the groups’ information needs. The CML program kicked off with the reference librarians attending key meetings determined by their individual groups. In 2006, another reference librarian was hired to join the staff to help extend the CML program’s reach to the nursing department. One of the first tasks for this new staff member was to provide mediated-literature searches to the nursing EBP committees. Involvement with Critical Care Medicine and embedding a librarian within this department was finalized in October 2009. The last group to be added to the program was the Breast Imaging Service in August 2013. All research informationists today are involved with a specific service or department as part of their overall job responsibilities.
As the CML program evolved, the informationists have forged strong relationships with their clients which have served them well. This has helped them to better understand the types of information their team requires for informed decision-making. They have proactively delivered on projects that matter. Overtime, the traditional role of the MSK reference librarian has been transformed to one of a team contributor. Table 7.1 highlights several key differences between the CML and reference librarian. They now anticipate, participate, and customize information based on the group’s needs and workflows; focusing attention on ongoing projects, key research topics of interest, and seeking opportunities to continue to strength their partnerships.
Table 7.1
| 1. Client centric not library centric |
| 2. Requires a proactive approach |
| 3. Focus on small groups—not entire library community |
| 4. Acquiring domain knowledge essential |
| 5. Results provided include analysis/synthesis of info |
The CML program does deliver value and each participating service or group (regardless of size) does require unique information services specific to their workflows and interests. The key to success is to determine client expectations, delivery on their expectations, and ensure that there is ongoing dialog and feedback for constant program enhancements.
7.3 Informationists’ role in support of systematic reviews
With the body of medical research and published papers growing at a rapid rate each year, how does a clinician or healthcare provider decide on what evidence is worth reading? The purpose of a systematic review is to conduct a comprehensive search, develop a reproducible criteria in the selection of articles that will be reviewed by the content experts on the team, and then summarize this available evidence to answer the specific clinical question posed. The end product is a publication that in itself represents a scientific investigation.
According to the Institute of Medicine’s (now referred to as The National Academies of Sciences Engineering Medicine (NASEM)) Standards for Systematic Reviews, when conducting a comprehensive systematic search for evidence, the following standards support the inclusion of a librarian:
- 1. Work with a librarian or other information specialist trained in performing systematic reviews to plan the search strategy.
- 2. Design the search strategy to address each key research question.
- 3. Use an independent librarian or other information specialist to peer review the search strategy (National Academy of Sciences Engineering Medicine Health and Medicine Division, 2011).
In addition to the standards outlined by NASEM, Cochrane is an international not-for-profit organization, and considered by many to be the gold standard in the systematic review field. Their publications have to meet a defined set of quality standards and their authors and editors have been conducting and providing systematic reviews for about 20 years. They are formed with the intention of organizing medical research findings to facilitate evidence-based decisions regarding health interventions that healthcare professionals are challenged with during the course of their careers in patient-care settings. Cochrane has also clearly defined the role of an information specialist and outlined a variety of ways in which this individual can add value to the process and final outcome (The Cochrane Collaboration, 2017).
The literature also supports a variety of reasons why having a librarian on the systematic review team is important. Research shows that engaging a librarian helps to improve the search strategy and their skills in literature searching impact the quality of research evidence found which later gets translated into clinical decision-making (Perrier et al., 2014; Rethlefsen, Farrell, Osterhaus Trzasko, & Brigham, 2015). Most importantly, librarians are able to deliver search strategies that are reproducible, set up search alerts if appropriate, and are able to effectively document in detail all steps involved in crafting the search algorithm and the key terms/controlled vocabulary used based on the selected database. The importance of the librarian’s involvement is further reinforced by some journal editors who will reject a systematic review of the manuscript that did not use the services of a librarian and recommend that the authors work with a librarian to improve the search strategy before resubmitting (e.g., Journal of General Internal Medicine).
7.4 The evolving role of the research informationist in EBP
The future of EBP is still evolving as the healthcare landscape changes rapidly with new innovations and therapies. Cancer research is one of the fastest changing fields in health care, moving from a philosophy of treating specific cancers with therapies shown to be the most effective at a population level through high-level evidence such as guidelines and systematic reviews, to a paradigm of precision medicine and treating individual patients based on their specific genetic and tumor makeup. This has led the way for numerous immunotherapy drugs, which harness the patienťs own immune system to kill the cancer, to the recently FDA approved gene-altering drug for leukemia, which genetically alters the patienťs own cells to fight the cancer. MSK is at the forefront of this new frontier of cancer research, partnering with the White House Cancer Moonshot initiative, which President Obama appointed Vice President Biden to head up. The Cancer Moonshot aims to not only improve access to cancer therapies for patients, but also increase the ability to detect and prevent cancer at earlier stages. The ultimate goal of the Cancer Moonshot is to make a decade’s worth of cancer research advances in just 5 years (The White House, 2016).
This paradigm shift in medicine is changing the core of EBP entirely. The basis of EBP has been, up until now, focused on the population level. The idea that what works for a large number of patients will work for the patient in front of them is fading, and with it the importance and value of aggregated evidence such as systematic reviews and metaanalyses in practice. The future of EBP is moving in a direction of aggregating individual patients genomes to identify candidate genes involved in disease and from there developing drugs and therapies to target those genes. Furthermore, although the patienťs preferences and values have always been a critical component of EBP, the move toward patient-centered care has led to the increased awareness of the importance of patient-reported outcomes in evaluating and improving upon the quality of health care.
The informationists must be able to adapt to these changes in medicine by modifying their services and providing new innovative services to their users. Many of the tenants of medical librarianship are still relevant, such as assisting and educating users on locating and using information, and providing resources to enhance their productivity. However, the new landscape opens up a variety of opportunities for informationists to support their users. From managing the vast amount of data being generated, to providing customized services and education, to embedding themselves into the projects and departments for more specialized services in real time, informationists can be the information experts and navigators in a research world that is quickly changing and evolving.
7.5 Case studies: Clinical Medical Librarian programs
7.5.1 Case study one: MSK CML in critical care medicine
The CML program has been involved with the Critical Care team since 2009. At first the role of the informationist was essentially a point person for the attending physicians, with sporadic reference questions, resource troubleshooting, and searches. As the relationship has progressed, the role expanded to be a visible information point person for all staff in the intensive care unit (ICU), from attendings and clinical fellows, to nurse practitioners and RNs, with a more embedded role in the daily functions of the ICU.
As the Critical Care CML, I address all the reference and search questions arising from ICU staff, and in keeping with the understanding that questions that arise in critical care are immediate needs, I attempt to return results to patient-care questions within 24 h. I also attend weekly Morbidity & Mortality (M&M) Reports, weekly Multidisciplinary Rounds, and occasionally the daily morning Attending Rounds, where if questions arise I can search in real time on my iPad and email articles to the rest of the team. Not only does attending these patient reports provide me with first-hand experience as to what types of patient scenarios and clinical questions arise in the ICU, but also it embeds me into the workflow of the ICU and gives me a visible role on the team. In meetings and on rounds, they recognize me and know why I am there and that they can come to me with questions.
The Critical Care CML has also been involved in a variety of special projects in the ICU, including the development of an iPad program designed to assist ventilated patients in communicating with their caregivers and family members. The application allows patients to communicate through touching a variety of pictures to describe things they may need, want, or feel; or they can use the program to type out what they want to say. Since the completion of the iPad application, my role in continuing this project has been in the training of staff and volunteers on how to use the program with patients.
One of the most challenging aspects to the Critical Care CML is keeping up with the discussions during reports. The ICU is a fast-paced environment with high patient turnover and a broad spectrum of clinical conditions. Rounds and M&M Report involve a quick description of the patient, including their primary diagnosis and status, and what brought them into the ICU. Questions may arise during this time for a patient with regards to diagnostics, treatment and tests, ethical issues, and psychosocial issues. Often, if a question or discussion arises during these reports, an attending or the chief will ask me if there is any literature or evidence related to the question at hand. However, sometimes during a discussion about a patient I see a question that there may be evidence in the literature to answer. In this case, I will run a search on my iPad and either show it directly to one of the attending clinicians, or send them an email with the article. For example, in a discussion about a patient who had a hypotensive episode during breast reconstructive surgery due to the change in an upright position, one of the fellows made a comment about how to prevent this if the patient decides to reattempt the surgery in the future. I heard this during M&M Report and quickly searched PubMed and located several studies looking at prevention of hypotension during upright surgeries. I emailed the articles directly to the entire team.
Since MSK was awarded Magnet Recognition in 2016 (MSKCC, 2016), nurses across the institution are required to take an EBP approach to research and their current practice as part of their responsibilities to enhance the quality of patient care and fulfill job performance expectations of the management. This has provided our library with the chance to have a significant impact on the evidence-based research being conducted throughout the institution and an opportunity for CMLs to provide even more services to their departments. In early 2017, our library worked with the nursing department to create a specialized PICO form (https://library.mskcc.org/services/picot-search) for nurses to submit their clinical research questions to the library for literature searches. The form requires the nurses to identify each part of their PICO question, guiding them on how to formulate a clinical question and how evidence-based research differs from general questions. The PICO questions submitted by the ICU nurses provide me with a deeper understanding of the future of the research and practice in critical care, but it also is a way for me to be able to proactively support ICU nursing community by anticipating their information needs.
7.5.2 Case study two: MSK CML in psychiatry and behavior sciences
The Department of Psychiatry and Behavioral Sciences at MSK (https://www.mskcc.org/departments/psychiatry-behavioral-sciences) is a very large and diverse group, which includes psychiatrists, psychologists, neuropsychologists, and other members involved in research and patient care, as well as, education. As an important resource for training and research in psycho-oncology, MSK offers two types of fellowships: a Clinical Fellowship in Psychosomatic Medicine and Psycho-Oncology and a Research Fellowship in Psycho-Oncology. As the informationist assigned to this group, I have a standing invitation to attend meetings and conferences scheduled as part of the academic program for the Clinical Fellows, including the psychiatry case review meetings. Otherwise, most of the information requests submitted from this group are received by me electronically via email, especially since the members of this department have offices distributed over multiple MSK locations and are not necessarily physically located on the main MSK campus as is the MSK Library.
The Department of Psychiatry and Behavioral Sciences is a client group that contributes to evidence-based health care in a variety of ways and at different levels (Jordan, Lockwood, Aromataris, & Munn, 2016), components of which can and should be supported by the informationist. For example, during their weekly psychiatry case review meetings, the Clinical Fellows present and discuss their new patients with their colleagues and the attending physicians. Being able to join the meeting as the group reviews all possible diagnosis and management options for the care of an individual patient gives me the opportunity to hear firsthand the background knowledge questions or clinical questions that often arise and can lead to subsequent literature searches. The role of the informationist in this type of search is to look for the best available evidence and in the most summarized/synthesized form so as not to overwhelm the clinician with too much information but rather to provide just the right amount of current information on which to base clinical decisions. Occasionally, questions prompted from an individual patient case have evolved into a research project that a Clinical Fellow embarked upon and that lead to a subsequent topic review publication that I was able to assist with by providing a comprehensive literature search (Edelstein, Pergolizzi, & Alici, 2017).
Alternatively, research fellows and faculty may be interested in carrying out systematic review research projects where they create new evidence syntheses for publication (Forcen, Matsoukas, & Alici, 2016). As the informationist on the team, I have supported such efforts not only by conducting the literature searching but also by providing training and guidance related to systematic review methodology, and by ensuring that the project work is carried out in the most transparent, well documented way, with a minimum possible introduction of bias into the process. Along the same lines, faculty in the department who are experts in their field may also be involved in developing evidence-based standards, guidelines, policies, and/or recommendations that will help further summarize the research evidence and make it more transferable to practice at the local, national, and/or international levels. As the librarian collaborator on a number of such projects, I have been assigned the role of ensuring that the search methods agreed upon by contributors for the systematic search and its documentation were properly adhered to (Lichtenthal et al., 2015; Wiener, Kazak, Noll, Patenaude, & Kupst, 2015).
Research informationists can also play a role in quality improvement projects by investigating interventions that may help with the implementation of EBPs that might improve upon what is currently being done locally at the institution. An example of this type of project is a multidisciplinary initiative for delirium screening and management in the ICU at MSK that I was recently involved with, including multiple departments, such as the Department of Psychiatry and Behavioral Sciences and Critical Care Medicine. This particular project led to an accepted poster abstract entry for the team in MSK’s annual Quality Improvement Fair. Consequently, my role as the informationist again expanded beyond taking care of the literature search requirements for the project to also include the provision of some technical assistance, including help with survey design and data management using REDCap, as well as, with the design of the scientific poster using MS PowerPoint. An important lesson that I have learned via my involvement in the CML program is that being part of a clinical/research team can offer many opportunities for the informationist to both participate and contribute to more significantly in the scholarly communication process in ways that go well beyond traditional “librarian” tasks.
7.5.3 Case study three: Establishing a systematic review service at MSK
In the summer of 2010, the Systematic Review Service offered at MSK was formalized and a LibGuide (Memorial Sloan Kettering Library LibGuides, 2017) was launched to explain the service and the role of the research informationist and what this individual would deliver as part of the systematic review team.
In preparation for our new service, a decision was made that all research informationists would attend relevant training prior to being assigned a systematic review request. We were aware that for the past several years, the Health Sciences Library System at the University of Pittsburg had been offering a systematic review workshop twice a year (Health Sciences Library System (HSLS) University of Pittsburgh, 1999–2017). This workshop provides a comprehensive framework, the theory and practice of systematic reviews, and how the informationist can prepare to become a team collaborator and facilitator in the systematic review process. The background and information learned would help set the tone and give each of them a baseline to move forward, as well as, build on their searching skills and their value as a coinvestigator on a systematic review.
We developed two key forms as part of our systematic review service workflow. The first is the request form which includes the requestor’s contact information, topic details, reason(s) for the systematic review request, and a space where the individual can share citations pertinent to the topic. The second form is used to record the initial discussion between the assigned librarian and the requester/team and serves as an historical document once the research is published. Both forms can be found on our Systematic Review Service LibGuide mentioned earlier. In addition, the LibGuide clearly outlines our roles and how we can help throughout the systematic review process.
We outline seven steps (see Table 7.2) to conduct a systematic review, and within each step, specific tasks that we as research informationists are ideally suited to handle. The obvious tasks include providing expertise in developing the search strategy and determining appropriate databases and gray literature sources; reviewing the literature to confirm if other systematic reviews exist on the clinical question posed; executing a preliminary search to decide if the search strategy requires refinement; setting up search alerts to monitor new publications if appropriate; and writing the section which details the search methodology. Other tasks that we can support relate to educational and training opportunities to work with our assigned systematic review team in providing bibliographic and citation management workshops, as well as, locating checklists or critical appraisal tools, or determining a shortlist of options on where to submit the research manuscript.
Table 7.2
| 1. Framing the question |
| 2. Assembling the team |
| 3. Crafting the search strategy |
| 4. Assessing the quality of the papers retrieved |
| 5. Summarizing the evidence |
| 6. Interpreting the findings |
| 7. Publishing your results |
Since the launch of our service, we have coauthored 34 systematic review publications (as of 07/21/2017) and have dozens in various stages of completeness. We showcase these publications in a separate tab on our LibGuide to draw attention not only to our accomplishments, but also to promote the final outcome of having this service available to our library community. Our contributions have been rewarded in repeat business and clients who understand that having one of us as part of the team can ensure that the best search strategy has been crafted, the right databases have been searched, and that they have support in obtaining the needed published literature.
In the fall of 2012, we developed and offered a four-part workshop on systematic reviews to the MSK Counseling Center, entitled “Demystifying the Systematic Review Process.” The workshop covers the history, structure, and characteristics of a systematic review; formulating the question and developing the search strategy; conducting the research, including an introduction to an array of databases available to search; and the investigator’s analysis and assessment of the literature. This workshop has been held several times and always results with incoming systematic review requests to partner with one of us on a proposed clinical question. Providing this type of training also serves to promote our expertise and how we integrate in the systematic review research process.
In the spring of 2017, we decided it was time to take a service temperature check. While we always debrief at the end of every systematic review assignment with the team (to better understand what we did right or where we could improve), we targeted all MSK authors who had published a systematic review within the last 2 years in collaboration with one of our informationists. An online survey (see Table 7.3 for survey questions) was developed and the survey link was sent via email. The total number of authors contacted for feedback was 44 and the library received a 50% response rate to the survey. Of the 22 responses, 95% rated their overall experience with the MSK Systematic Review Service and their assigned informationist as “excellent,” “very good,” or “good,” and stated that they would recommend their colleagues to collaborate with an informationist on a future systematic review.
Table. 7.3
| 1. How do you rate the overall MSK systematic review service and working with your assigned research informationist (librarian)? |
| 2. How do you rate the knowledge and quality of work completed by your assigned research informationist (librarian) on your systematic review? |
| 3. Can you share at least one reason WHY OR WHY NOT having a research informationist (librarian) on the systematic review team IS OR IS NOT beneficial/productive? |
| 4. If a colleague was thinking about conducting a systematic review, would you recommend that they include a research informationist (librarian) on their team? |
| 5. Please share any additional thoughts you have regarding the MSK systematic review service. |
The majority of respondents saw having one of us involved in their systematic review as essential for producing the highest quality searches and methodology. One respondent stated that “their knowledge of search strategies combined with the added credibility of having a research librarian as a coauthor is essential.” Another respondent even expressed that “having a librarian on the systematic review team…should be a requirement for ALL systematic reviews and that journals should require it.” Many of the respondents expressed their appreciation of the Systematic Review Service, stating that “MSK Research Informationists add tremendous value,” and “looking forward to publishing more soon!”
As with all service initiatives, user feedback, both positive and constructive are essential. They provide valuable insight into what our clients are thinking and help us to improve and hopefully exceed their expectations. Our Systematic Review Service has definitely provided an opportunity for the informationist team to be more intimately involved with research topics and evidence-based outcomes that impact our users, and the research community that extends beyond the walls of our institution.