Monday, July 21, 2008

Barriers to use and referral: challenge

As time has passed I have been able to identify some of the potential barriers to use and to referral. I thought I would share these as they may benefit those of you who are interested in implementing a similar health information service at point of care (I know of at least one other centre that is considering doing so). That said I feel I should emphasize that this is based on my own personal observations and on the casually reported observations of others, rather than on any systematic study of the issue. We do intend to do a formal evaluation of the service, at which point we will be able to see whether these hypothesis are correct.

Not in order of importance:
  1. Distractions in the waiting room. We have two big, beautiful, flat screen TVs in the waiting room that are impossible to ignore if you're sitting there, no matter which way you're facing. I just went out there to see what's playing. On one you have a talk show and on the other a soap opera. Even on mute they seem to be serious competition for my service. Gone are the interminable boring waits during which patients had time to think about where they were (the doctor's office), why they were there (sickness, checkup etc.), and maybe formulate a few questions they'd like answered. You may want to think about what could potentially distract your users from dropping in with questions. It could be TVs. It could be something else.

    The good
    a) patient satisfaction no doubt increases (time flies when you're having fun), b) as far as the TVs are concerned, there is an opportunity for promotion, to develop programming that could include information about the clinic and the service. The bad people may be distracted from asking questions while they wait.

  2. The InfoRx. On the part of the HP, there may be uncertainty about how to insert the referral into a transaction with the patient. It may be hard for HPs to know when would be a good time to mention it, or who might benefit. Time is certainly a factor and it is probably all too easy to forget to write up an InfoRx. Telling HPs that they should consider referring a patient whenever they make a new diagnosis, prescribe a new medication, or the patient is faced with a treatment decision may not be enough. The idea that a librarian is now acting as a member of the team at point of care and can have patients referred to them same as any other specialist may be new and it may take a long time before knowledge becomes practice, even when everyone buys in to the idea. My feeling is that this is a change management issue. It has to do with the gap between theory and practice, between intention and action.

    Hoping to find something along the lines of the PLISSIT model* that could be used to assist health professionals at that crucial moment during their visit with the patient and family, I've been doing some reading about barriers to improving practice, and barriers to implementing practice guidelines and shared-decision-making. I think the latter is particularly relevant, because helping a patient or family member become well informed is a crucial component of the shared-decision-making process.**

    The bad this is a very complex issue that may be difficult, if not impossible, to solve, The good this could be an opportunity to further develop a new model of health care, and there may be evidence to help us in the process.

  3. The Internet. You will likely wish to have a web component to your service, as I have done. Our website is advertised in our H-PHIS brochures which are disappearing from the displays at a steady rate. Statistics show that the website is being visited regularly. From this I feel I can say that I am successfully helping people help themselves. I wonder if this makes them less likely to ask for help.

    The good
    people will probably use a website if you have one, The bad people may go to your website instead of using your service.

  4. Availability. It is unlikely that you will be on site and available every day all day. I am only on site 7 hrs per week, and the librarian at the Monkfield Medical Practice was also there only part time. This means that you may not always be available when needed, and not always be around to remind people to use the service and to guide people through the process. The point of having a service on site is to avoid the whole "out of site out of mind" thing.

    The good
    the demand may be greater than the supply, which may justify an increase in staffed hours The bad not having enough hours to make the service work.
I would love to know your thoughts on these issues, so any comments or suggestions from my readers are very welcome. Since I began writing this post I have found a couple of models that may be useful in facilitating shared-decision-making. Stay tuned. I will discuss them in my next posts...

I came across this model recently while researching the question of how to help HPs bring up sexuality issues with gynecologic cancer patients.

Haines A, Kuruvilla S, Borchert M. Bridging the implementation gap between knowledge and action for health. Bulletin of the World Health Organization 2004;82:724-32.

Cabana MD, Rand CS, Powe N, et al. Why don't physicians follow clinical practice guidelines?: A framework for improvement. JAMA 1999;282(15):1458-1465 (doi:10.1001/jama.282.15.1458)

Freeman AC, Sweeney K. Why general practitioners do not implement evidence: A qualitative study. BMJ 2001;323:1100-2.

Gravel K, Legare F, Graham ID. Barriers and facilitators to implementing shared-decision-making in clinical practice: A systematic review of health professionals' perceptions. Implementation Science 2006;1:16. (doi:10.1186/1748-5908-1-16)

These are just a few of the articles I've found. I will try to include a more detailed list in a future post.

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