Electronic Letterhead Template
FACULTY OF MEDICINE
Continuing Medical Education
TRW Building
3280 Hospital Drive NW
Calgary, Alberta Canada T2N 1N4
T +1.403.970.6742
F +1.403.210.9247
E
ucalgary.ca
DynIA: Dynamically Informed Allegories
A knowledge translation project, combining webinars, virtual patients and asynchronous discussion around clinical practice guidelines on chronic pain.
Co-Principal Investigators: Paul Taenzer and David Topps
Co-Investigators: Heather Armson, Eloise Carr, Rachel Ellaway, Cathlin Mutch, Ashi Mehta
Funding: Canadian Institutes of Health Research (CIHR)
Parent organizations: University of Calgary and McMaster University
Project dates: Jan 1st 2013 – March 31st, 2014.
Theme 4: Lay Summary
An important strategy for improving population health is to use what we learn from medical research in our patient care. One approach to this is using the highest quality medical research to make recommendations and guide healthcare providers in deciding how to diagnose and treat their patients. These recommendations form the basis of healthcare tools that are called clinical practice guidelines.
Theme four focused on strategies for increasing the uptake of clinical practice guidelines on low back pain and headache into community-based care. Theme four researchers collaborated with guideline developers in Alberta at the Institute of Health Economics and an organization called Towards Optimize Practice (TOP) that is sponsored by the Alberta Medical Association and the Alberta Ministry of Health (Alberta Health and Wellness).
The research team first looked at what is already been known about uptake of guideline recommendations for chronic pain. This process involved going back to original research from around the world. Research librarians and scientists found 19 scientific papers that are relevant. Taken together, these studies indicated that the best approach to improving uptake of chronic pain guidelines into community care is to present them to care providers in special interactive educational settings where they are able to discuss the recommendations approaches with the educators.
Theme four then went on to test this approach in the study of using an interactive educational workshop focused on the low back pain guideline. The study was conducted in collaboration with researchers from the University of Calgary and the University of Alberta. The workshop presenters were an expert team of physicians, physiotherapists, nurses and psychologists that traveled to the offices of the community healthcare providers. This study showed that the providers’ knowledge of low back pain increased after the workshop. When the medical records were examined, the researchers were unable to detect changes in how care was provided. This was a small study involving 24 providers. The researchers concluded that a larger study may confirm the increase in provider knowledge and detect changes in care.
An important advance in healthcare is the use of computerized medical records. Computerization also provides an opportunity for healthcare providers to access relevant health information during their time with the patient. Theme four researchers collaborated with the Department of Family Medicine that McMaster University to develop a tool to help community caregivers use the recommendations from clinical practice guidelines while they are in the office with patients. This tool called the McMaster Pain Assistant has undergone successful usability testing and is now being tested in the community to see if using the tool leads to increases in knowledge and decisions that reflect the guideline.
Rural physicians face important challenges in accessing medical education. In the past they would have to leave their practices and travel to a distant site to learn. Theme four researchers collaborated with the Department of Continuing Medical Education at the University of Calgary to explore a distance learning approach using Internet-based webinars and “virtual patients” that are designed to teach about the guidelines and how it might affect their care. This preliminary study demonstrated that rural physicians appreciated being able to access high quality medical education where they can interact with experts without having to travel. They found the sessions and the virtual patients highly engaging and realistic. Only small changes were shown in management of the virtual patients through the case series. Detailed analysis of practice patterns showed participants to be very conformant with clinical practice guideline recommendations.
Theme 4: 1) Study Objectives/Research Questions
Theme four:“Partnering with the Alberta HTA Chronic Pain Ambassador Programme” undertook of four distinct studies all of whom were related to knowledge translation to primary care providers for guideline implementation. The research questions for each project are described below.
We undertook a systematic review of the research literature on knowledge translation for guideline implementation for both primary care providers and for patients. The objectives were to determine the effective strategies for knowledge translation from the world literature on guideline implementation for these populations.
We also undertook a preliminary study of an interprofessional interactive workshop to engage primary care providers on how the guideline recommendations could be implemented in their practices. We sought to answer the following questions: 1) Does participating in the workshop improve physician knowledge of best practice in low back pain assessment and management 2) Do physician practice patterns demonstrate improved compliance with evidence-based guidance and 3) Is it feasible to recruit for a larger randomized trial to assess the impact of the workshop using this study design?
We partnered with the Department of Family Medicine of McMaster University to develop a computerized decision-support (CDSS) tool for the OSCAR electronic health record. This tool is designed to support multidisciplinary pain providers in conducting and documenting primary care chronic pain visits. The tool has guideline recommendation based advice as well as easily accessible patient education handouts and videos, standardized practice relevant measures for screening for clinical “red flags” and risk factors for chronicity as well as for tracking patient progress. The tool incorporates the pharmacological guideline for neuropathic pain as well as the Alberta low back pain guideline. Funding for the neuropathic component and the outcome study (study four) are provided through a grant from the Lawson health Institute from the University of Western Ontario. Four projects have been undertaken, including interviews and focus groups with providers and with patients to answer the following research questions: for providers; what are the challenges in treating patients with chronic pain, what are the challenges in using electronic health records, what would you like to see in a chronic pain CDSS? For patients; how could the electronic health record improve your interaction with your primary care provider, would you like to contribute to and have access to the electronic health record? The third study addressed the usability of the iterative drafts of the decision-support tool to identify how users were interacting with the draft CDSS. The final study that is currently underway utilizing funding from another grant is exploring the impact of the tool on provider knowledge and practice patterns and addresses the question: does using the computerized decision-support tool lead to increased knowledge and compliance with the guideline recommendations?
We also collaborated with researchers from the University of Calgary Department of Continuing Medical Education in a pilot study exploring the feasibility of using interactive webinars and virtual patients and secured internet discussion forums of low back pain and headache as a strategy for providing distance education regarding the guideline recommendations. The project explored the following research questions: 1) are these feasible tools for promoting evidence-based practice in primary health care; 2) are these tools and acceptable for physicians for improving clinical management in chronic pain conditions ; 3) will the tools lead to improvements in knowledge, clinical reasoning skills and confidence in managing primary care patients with headaches and low back pain.
Theme four: Methods & Measures
The systematic review of KT strategies for chronic pain was undertaken by a health technology assessment specialist at the Institute for Health Economics and used standardized methodologies for the literature search and quality appraisal. Clinical expertise for reviewing the relevance of potential research studies was provided by members of the theme four research team.
The preliminary study of the interactive workshop recruited 21 physicians from four Alberta practices and used a pre-post single group experimental design. Outcome measures included a standardized knowledge survey of assessment and treatment of low back pain, a chart audit of practice behaviours and the measure of satisfaction.
The needs assessment studies of providers perceptions of the challenges of treating chronic pain and of using the electronic health record and desirable characteristics of a computerized decision-support tool as well as the patient needs assessment regarding potential benefits of such a tool used a structured interview format for both individual interviews and focus groups. Qualitative analysis was undertaken to determine the recurrent themes in the interview transcripts. 21 clinicians and 12 patients participated. The usability assessment study involved 12 clinicians who were observed using the draft CDSS over two iterations of development. A System Usability Scale (SUS) was used to obtain a numerical rating of their impressions.
The feasibility study of interactive webinars and virtual cases also used a pre-post design with the knowledge assessment measurement derived from the responses to the virtual cases. We used an emerging methodology called “script concordance testing” which has been used in the past in medical education to evaluate students’ clinical reasoning by comparing participants and experts in their decision-making styles. Satisfaction with the webinars and virtual cases was also collected.
The study recruited 22 physicians from three rural Alberta communities. Outcome measures included pre- and post- structured online surveys, a focus group discussion with each site visit, and detailed analytics around clinical reasoning (using the virtual patient software). Qualitative analysis conducted for recurrent themes around barriers to implementing CPG recommendations, driven by virtual patient case specific material.
Theme 4: Key Findings
The systematic review to assess the effectiveness of knowledge translation studies for chronic pain used a comprehensive search strategy of electronic databases, the gray literature and hand journal searches to identify appropriate RCTs and controlled studies. 19 studies were included. Interactive education for health providers showed positive affects regarding provider knowledge and patients’ functional capacity. Benefits of KT strategies for other health providers and for patients were less clear.
The low back pain workshop preliminary study found that physician knowledge improved after the workshop. However the chart audit of physician practice behaviour was inconclusive. Participating physicians found the workshops helpful and appeared to increase knowledge however the significance of knowledge acquisition on practice is unclear.
The focus groups for the CDSS study involved 21 clinicians and 12 patients. Clinicians identified that a CDSS could facilitate continuity of care, provide a ‘backbone’ when feeling pressured to prescribe narcotics as the CDSS could focus on guidelines and they appreciated that the CDSS could provide longitudinal information for helping understand how the patient’s pain had changed over time. Strategies to support the use of the CDSS included having data entered in one spot populate appropriately in other areas, minimum of “clicks” to manoeuvre through the chart and hyperlinks to other pertinent information such as patient education materials and instructional videos. Patients felt that if clinicians can easily access their history of pain management including medications that this could result in better interaction with their providers.
The DynIA project involved 22 clinicians in a series of 3 webinars, 27 virtual patient cases and an asynchronous discussion forum. There was tight integration between virtual patient material and webinar content, which created a highly engaging set of activities. All of the sessions ran over time, even though this cut into private time with no reimbursement. Strongly positive qualitative comments were garnered about the challenging and realistic nature of the case and webinar material. Participants were highly committed to completing pre-webinar case material, which is highly unusual for CME events. Case management of the virtual patients correlated closely with expected pathways as suggested by the clinical practice guidelines in most areas. An unanticipated benefit of this project was the development of a powerful, scenario-based set of educational activities, with detailed underlying analytics that will facilitate further findings.
Theme Four: Implications and Actual or Potential Impact
Theme four has two likely impacts.
The first being the publication of the systematic review identifies the “state of the science” for knowledge translation and chronic pain. Individuals and agencies will find this review an important resource in designing their knowledge translation strategies for primary care providers. The preliminary study of the interactive education workshop is consistent with the systematic review and sets the stage for further work in this area.
The computerized decision-support study and the study of webinars and virtual patients both suggest that these innovative ‘technology enhanced’ strategies for knowledge translation are feasible for use with primary care providers. The virtual patients provide a means by which clinical reasoning can be explored with detailed analytics. These studies are preliminary and encourage further research into these approaches.