Multifaceted Online Interventions to Increase Clinicians Searching of Current Best Evidence to Answer Clinical Questions

Translation of new knowledge from research into evidence-informed health care is a shared obligation of the clinical and the scientific communities. Unfortunately, studies of quality of care continue to show that this goal is substantially unrealized. One main barrier is lack of quick and easy identification, appraisal and synthesis of current best evidence. Clinicians' information have 5 to 8 questions about individual patients per daily shift, but face a large volume of 3000 articles published every day, accessible in many scattered resources.

To address theses problems, McMaster's Health Information Research Unit (Hamilton, Ontario, Canada) has developed and implemented "McMaster Premium LiteratUre Service Federated Search" (MPFS), an online search engine that provides a unique 1-stop search and organized access to current best evidence in daily practice. However additional barriers need to be overcome for clinicians to actually search and use this evidence in their practice. Theses include logistical barriers (time constraints, forgotten questions), as well as educational barriers (eg, lack of awareness of the "architecture" of evidence, limited searching skills, and lack of reference standards among peers for finding best evidence).

This randomized trial seeks to test 3 innovative online interventions among clinicians registered to MPFS to overcome these barriers and increase the quantity and quality of searching for current best evidence to answer clinical questions. These interventions build on effective models for the teaching of clinical skills at the point of care, so that clinicians are facilitated in using the search engine as a clinical tool, and perceive evidence retrieval skills as true clinical skills.

1. Rationale \& Objectives

   One main barrier to achieving evidence-informed care by clinicians is lack of quick and easy identification, appraisal and synthesis of current best evidence. Clinicians' information needs are considerable - but about 3000 articles are published in Medline every day. Numerous evidence-based resources have been developed to filter and process the evidence, but although increasingly used by clinicians, each offer a fragmented and scattered view of information, and none provides comprehensive topic coverage or satisfactory updating.

   To address theses problems, McMaster's Health Information Research Unit (Hamilton, Ontario, Canada) has developed and implemented "McMaster Premium LiteratUre Service Federated Search (MPFS)", an online search engine that provides a unique 1-stop search and organized access to current best evidence in daily practice. MPFS provides both alerts to users about new research in their chosen disciplines, and a novel federated search function, with the particular feature of organizing information according to the "pyramid of evidence-based resources", with the most clinically applicable evidence at the top. Thus MPFS simultaneously retrieves evidence from Studies ("Medline", both filtered and unfiltered, at the bottom), then Systematic reviews; Synopses of studies and systematic reviews (selected for methodological rigor and clinical relevance), and, at the top level, online widely used Summaries (e.g."Best Practice").

   Combining features of the current best evidence-based resources is not enough to increase access and use of current best evidence, as shown by the relatively low utilization of searching features among the hundreds of clinicians currently registered at McMaster University and using the alerting system. Additional well-known barriers that need to be overcome include logistical barriers (time constraints, forgotten questions, and simplicity of using one single albeit limited resource), as well as educational barriers (eg, lack of awareness of the "architecture" of evidence and limits of other single resources, lack of knowledge and experience of what federated searches can offer, limited searching skills, and lack of reference standards among peers for finding best evidence).
2. Hypothesis

   This trial seeks to test 3 innovative online interventions among clinicians registered to MPFS to overcome these barriers and increase the quantity and quality of searching for current best evidence to answer clinical questions. These interventions build on effective models for the teaching of clinical skills at the point of care, so that clinicians are facilitated in using the search engine as a clinical tool, and perceive evidence retrieval skills as true clinical skills.
3. Methods

   1. Study design: Randomized Factorial Controlled Trial.
   2. Setting and Participants: The trial will be conducted among postgraduate and faculty MD registered in MPFS and working in the teaching hospitals and clinics of McMaster University (see eligibility criteria below)
   3. Participating clinicians will be randomized to 3 online interventions (see description below) in a factorial design (A x B x C), whose permutation results in 8 allocation arms (A+B+C, A+B, A+C, B+C, A, B, C, no intervention, see details below)
   4. Randomization: will be computer-generated, stratified training level (post-graduate MD, faculty MD), and baseline frequency of searching for evidence on MPFS. Registrants will be randomly allocated to each study arms. Allocation will be concealed from research staff.
   5. Blinding and control group: Although participants cannot be blinded to the interventions, they will not be told of the different features offered, and all will receive usual searching features of MPFS.
   6. Primary and secondary outcomes (see below).

Eligibility Criteria:
Inclusion Criteria:

* All postgraduate and faculty physicians currently registered for more than one month in the MPFS search engine,
* and working in the teaching hospitals and clinics of the Faculty of Health Sciences, McMaster University, Hamilton, Ontario.

Exclusion Criteria:

* Registrants that are no longer working or training at McMaster University,
* Registrants that never logged in MPFS during the last 12 months counting back from the beginning of the trial.