Clinical guidance for health workers (2)

8 February, 2020

Dear Sandeep and HIFA colleagues,

Sandeep Saluja writes: "from the perspective of a health care worker or doctor confronted with a clinical issue what is important is to be able to get a direct response to his or her query... Can some members of HIFA form a group which takes the lead in this direction?".

Thank you for raising this critical issue. Indeed, it would be good to start by re-evaluating how health workers obtain such information currently.

I am reminded of a 1996 BMJ paper by HIFA member Richard Smith:

CITATION: What clinical information do doctors need?

BMJ 1996; 313 doi: https://doi.org/10.1136/bmj.313.7064.1062

Richard Smith

ABSTRACT

Summary points:

- Doctors use some two million pieces of information to manage patients, but little research has been done on the information needs that arise while treating patients

- Textbooks, journals, and other existing information tools are not adequate for answering the questions that arise: textbooks are out of date, and “the signal to noise” ratio of journals is too low for them to be useful in daily practice

- Computer systems that have been developed to help doctors are not widely used—perhaps because they have not been developed to meet doctors' information needs

- When doctors see patients they usually generate at least one question; more questions arise than the doctors seem to recognise

- Most of the questions concern treatment

- Many of the questions are highly complex, simultaneously asking about individual patients and particular areas of medical knowledge

- Often doctors are asking not simply for information but for support, guidance, affirmation, and feedback

- Many of the questions go unanswered, but most could be answered; it is, however, time consuming and expensive to answer them

- Doctors are most likely to seek answers to these questions from other doctors

- The best information sources provide relevant, valid material that can be accessed quickly and with minimal effort

- New information tools are needed: they are likely to be electronic, portable, fast, easy to use, connected to both a large valid database of medical knowledge and the patient record, and a servant of patients as well as doctors

Many of these observations are relevant today, although of course much has changed and been debated/published since.

The question of understanding the information and learning needs of health workers - and how to meet them - lies at the heart of what HIFA is about, and perhaps Sandeep's message can spur us to address this more rigorously and systematically. For example, HIFA's expert working group on Information for Prescribers and Users of Medicines has recently submitted a paper 'How do primary healthcare workers in low-income and middle-income countries obtain information during consultations to aid safe prescribing? A systematic review', whose protocol is available here: https://bmjopen.bmj.com/content/9/1/e023015 We would very much like to hear from other HIFA members on this and related topics.

One way of looking at the question, with reference to immediate clinical questions relating to patient care, is spatially, in terms of:

1. retrievable knowledge and reasoning (this applies, for example, in the case of the management of many common illnesses with which the provider is very familiar - although it is salutary that healthcare provider practices can sometimes be grossly wrong in their choices, even for common diseases)

2. point-of-care information (for example, a clinical guideline, manual or drug formulary, whether printed or electronic)

3. discussion with and guidance from other immediate healthcare team members

4. guidance from in-country specialists (many generalists have professional contacts with a range of specialists whom they can call for advice)

5. information from international specialists and networks...

With regard to #5, we do need a better picture of the range of professional networks and services that provide such information, particularly on a case by case basis. I am thinking for example of the Swinfen Charitable Trust, which links clinicians in low- and middle-income countries with experts globally. I am sure there must be others and look forward to learn about them.

In the meantime, we should keep looking to enhance the availability and use of information locally.

Best wishes, Neil

Let's build a future where people are no longer dying for lack of healthcare information - Join HIFA: www.hifa.org

HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - www.hifa.org ), a global community with more than 19,000 members in 177 countries, interacting on six global forums in four languages. Twitter: @hifa_org FB: facebook.com/HIFAdotORG neil@hifa.org