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.

Promotion: challenge

I have discovered that promotion is a huge and ongoing component of what I do at the clinic (and in the library as well). Without it I could easily be forgotten, no matter how useful my service is and how necessary, because it is new.

Last week I began distributing our new brochure. I've placed them at strategic points throughout the clinic and was pleased to discover that more than 20 were missing a few days after I first put them out, and I have had several requests from non-referred patients. Success!

Lull or languish?: challenge

First I must apologize for not posting anything last week. I had some last minute consulting work that absolutely had to get done by the end of the day. I also had another reason for not posting, one that brings me this week's topic, which is that I have not had a case to post in the past couple of weeks. It is too soon to tell whether this is the beginning of a trend, or whether the holidays are coming and the snow is piling up and people have their minds on other things. It is probably a bit of both.

In any case it will soon be time to promote the service again, to both staff and patients/families.

Promotion is a tricky thing. You don't want to overload people with email reminders and fliers and posters and so on because you risk having them tune out and basically ignore the message. On the other hand you don't want to be completely passive about it, quietly hoping that people with remember you exist.

We had already decided that I would make up a brochure for the service which I could then hand out to people in the waiting room, and place strategically around the clinic. Now the thought is that we also need to make the space more welcoming. Right now it looks like an office and when people come in it is usually to apologetically capture a straying child, because they think I am someone else, or because they need a telephone. Only very rarely has someone come in to browse the pamphlets or ask a health information related question.


The first step has been to improve signage. I made an unfortunate mistake when I ordered our sign. See if you can spot it:**


Mistakes are often opportunities in disguise. Our new sign will not only have a correct title, it will also have a large red arrow pointing to the entrance and an invitation to drop in and ask questions.

In addition to the new sign, on my list so far are:

• A smaller, less obtrusive, desk for me
• A name plate for my desk
  
• Posters for the walls
• A comfortable chair (or two, depending on space)
  
• More shelves for pamphlets
• More pamphlets
  
• A computer for patients to use (part of our original plan for the room and already ordered)

The filing cabinet can be moved away from the door further opening up the space.

Hopefully the combination of promotion and space redesign will increase use of the service in the new year. I will keep readers updated.



** The word "health" was left out of the English title, completely altering the sense.