Getting to the evidence

Information sources for evidence-based care are proliferating rapidly. They are also updated very frequently. It doesn't take a genius to see that electronic access from the user's normal workplace is the only feasible way to bring evidence-based medical practice into everyday use. It's even in The New NHS white paper, and is supported by the King's Fund in its promoting action on clinical effectiveness programme.

But networking is just the starting point. There are huge questions over sourcing quality information, integrating external and local knowledge, converting evidence into clinical guidance, agreeing presentation formats and, of course, keeping it all up to date. And there is not much in the literature about how people have gone about doing this. Many trusts, health authorities and primary healthcare teams have therefore evolved a piecemeal and fragmented approach.

Anglia and Oxford regional office has instead tried a more strategic approach, based on the experiences of clinicians at some of its knowledge skills workshops.

The starting point is to establish an evidence centre, treating this as an organisation-wide change management project. For this you need a multidisciplinary project team, with clear links to the clinical effectiveness strategy. Library and information staff will have to become 'information brokers' who work with clinicians, audit and research and development staff to deliver and audit care according to the evidence base.

The team will have to make early decisions about how to generate the content. This can be done in a decentralised way, controlled by agreed design guidelines, or by a central dedicated team. And integrating the clinical, library, patient administration, executive information and office systems has to be a pre-planned part of the organisation's information management and technology strategy.

Two trusts are using this approach to try to build intranet-based evidence centres.

The United Leeds Teaching Hospitals trust has adopted a staged development approach. Intranet development is headed by Ted Woodhouse, the trust's information services director, who is planning to use its intranet as a trust-wide communications tool. The intranet already transports pathology results to wards, using a web browser interface to a pathology results server. Internal e-mail users have now reached a 'critical mass' of 2000.

The intranet includes the telephone directory, information pages on different parts of the trust, clinical protocols, personnel and nursing policies and procedures. Clinicians, audit, research and development, IT and library staff have added databases, including Medline and CINAHL, the cumulative index of nursing and allied health literature.

Mr Woodhouse, who is on the trust's clinical effectiveness strategy group, has yet to work out how best to integrate the clinical knowledge on the intranet, along with pathology results, into clinical workstations.

At present, different clinical areas are developing material, such as a hypertext pathology handbook, accident and emergency protocols and trust nursing procedures. But the problems of different design standards and ways of navigating the material are becoming apparent.

As there is no dedicated data capture resource, 'decentralised' development of data content is the only practical way forward in the short term. So ULTH has appointed a webmaster and is developing intranet policies to ensure uniformity of data management and presentation. The aim is to design a search engine that will work across all content on the intranet.

Although ULTH has large numbers of e-mail users, it still has to upgrade some PCs to run web browsers. It will have to review all its PCs as part of the millennium compliance project anyway, so intranet requirements will be added during this process. The trust also has to revise its IM&T strategy as part of the 1 April merger with St James' and Seacroft University Hospital trust, which will almost double the number of medical professionals to over 1,000.

But the information is not to be restricted to clinicians. Nurses, pharmacists and pathology lab staff are also keen to participate. The merged trust also has 5,000 nurses, 926 paramedics and 272 scientific staff - all of whom are potential users of the clinical knowledge database service. 'We are keen to provide access for all healthcare staff who need it,' says strategic project manager Marion McGowan.

Even management will be allowed access, though plans to link to their executive information systems will have to wait for the merger dust to settle.

A few miles down the road, Bradford Hospitals trust has set up an intranet project to share both clinical and administrative information.

Corporate affairs director John Dammon is chairing a project board of six consultants, who between them cover the whole clinical spectrum - including the trust's clinical effectiveness strategy. Brent Walker of the information services department runs the project team, which includes the technical, library, medical illustration and clinical effectiveness staff, and is creating and maintaining the information content.

The team quickly ran into problems in generating the data content - especially clinical protocols, which come in a variety of formats. So the trust has decided to allow specialty departments - and even individuals - to create web pages locally, provided that they comply with design standards. So far, the intranet is carrying protocols from the obstetrics department, theatre, and vascular surgery.

Bradford has just been declared a health action zone and will be under pressure to extend the project into the community as rapidly as possible, says Mr Walker. Seamless care for diabetes patients is likely to be a significant new application for the extended intranet, he predicts.

Ian Smith works for Secta Consulting and Judy Palmer is director of the healthcare libraries at John Radcliffe Hospital.