The role of smartphones in information-seeking behaviour among primary care clinicians: evaluating evidence to support high-quality patient care

• Main Author: Lee, Mauricette Moling
• Other Authors: Lorainne Tudor Car
• Format: Thesis-Doctor of Philosophy
• Language: English
• Published: Nanyang Technological University 2024
• Subjects: Medicine, Health and Life Sciences
• Online Access: https://hdl.handle.net/10356/173461
• Institution: Nanyang Technological University

Access to the best available healthcare evidence is essential for clinicians to provide high-quality patient care. To meet their information needs, clinicians search for relevant information using various sources, which is known as information-seeking behaviour. Smartphones, increasingly used by clinicians in their clinical practice, have created new opportunities for information access. In July 2018, the Singapore Ministry of Health introduced internet surfing separation as a security measure due to a patient data privacy breach, limiting the internet access of public sector primary care clinicians at the workplace. It is not uncommon for healthcare systems worldwide to be targeted by cybercriminals. To the best of my knowledge, however, remedies taken by the health industry did not include restricting internet usage at work. Internet surfing separation is when limits on searching the internet were enforced in Singapore public healthcare institutions, reducing internet access. As a result of limited internet access in Singapore public healthcare institutions, it presents a unique opportunity for investigating how primary care clinicians seek information. Consequently, unconventional needs, behaviours, and barriers may result. This unique factor may limit the generalisation of results to other contexts. On the other hand, researchers, policymakers, and clinicians may learn fresh knowledge or a different perspective. This aspect about internet surfing separation is less important for the other thesis studies, which do not focus on Singapore public healthcare. This project aimed to explore and report on using smartphones for information needs and the information-seeking behaviour of primary care clinicians. Firstly, a (1) scoping review was conducted to map the literature and the gaps in evidence on the use of smartphones by doctors within their clinical practice. Secondly, (2) the clinical information needs and information-seeking behaviour of primary care clinicians in Singapore were explored through semi-structured in-depth interviews followed by qualitative data analysis. Thirdly, (3) primary care clinicians' clinical information needs and information-seeking behaviour at the point of care in Singapore were investigated through brief semi-structured interviews administered after a clinical session and later qualitative data analysis. Fourthly, to (4) identify and evaluate the quality and content of smartphone apps that provide point-of-care evidence-based clinical information summaries through a systematic assessment of apps. Finally, (5) the effectiveness of educational interventions for improving information literacy in healthcare professionals was assessed through a systematic review. Scoping review Published paper: Lee, M., Mahmood, S., Lee, E.S., Smith, H.E., Tudor Car, L. Smartphone and mobile app use among doctors in clinical practice: a scoping review. Journal of medical Internet research mHealth and uHealth. Seven of the ten studies included in the scoping review recruited general practitioners as the participants. The results from the scoping review revealed that general practitioners and specialists use smartphones and mobile apps for communication, clinical decision-making, drug compendium, medical education and training, maintaining health records, managing time, and monitoring patients in clinical practice. One commonly reported barrier to the usage of smartphones among general practitioners and specialists at work included insufficient regulation and control. Qualitative study 1 Submitted paper: Lee, M., Tang, W.E., Smith, H.E., Tudor Car, L. Identifying preferences, barriers, and facilitators of primary care clinicians in seeking information for their clinical practice in Singapore: a qualitative study. BMC Primary Care. The in-depth interviews showed that most primary care clinicians sought clinical information daily at the point-of-care for various reasons, including clarifying doubts, personal interest, and self-improvement. Clinicians frequently reported using smartphones to seek clinical information. The barriers to information-seeking include the lack of time, internet surfing separation of work computers, the limited search function on their computers and limited access to evidence-based medicine databases. The facilitators included convenience, ease of access, and trustworthiness of the information sources. Qualitative study 2 Submitted paper: Lee, M., Tang, W.E., Smith, H.E., Tudor Car, L. Information-seeking behaviour of primary care clinicians in Singapore at the point-of-care: a qualitative study. Health information and libraries journal. Brief semi-structured interviews with primary care clinicians after their clinical sessions showed that two-thirds of clinicians had about one clinical question during their clinical session, and about half of the clinicians found answers to their clinical questions. Clinicians also commonly reported seeking clinical answers from their patients and using smartphones to access the Google search engine and UpToDate app. Some clinicians found it challenging to understand evidence-based medicine concepts. The barriers and facilitators to information-seeking were largely the same as in the in-depth study with the point-of-care study. Systematic assessment of apps Published paper: Lee, M., Lin, X., Chai, J.Z.Q., Lee, E.S., Smith, H.E., Tudor Car, L. Smartphone apps for point-of-care information summaries: systematic assessment of the quality and content. BMJ evidence-based medicine. The systematic assessment assessed the editorial policy, coverage of medical conditions, content development and trustworthiness of apps created specifically for healthcare professionals. Eight medical apps providing point of care evidence summaries were systematically appraised. Based on the assessment, about 30% of information relating to the editorial quality and 47.5% of information relating to the evidence-based methodology were unclear or missing in the included apps. All apps were only available in English, except for UpToDate, which was also available in 15 languages. Bullet points and brief paragraphs were used in all apps. Only DynaMed and Micromedex, and Pathway-medical knowledge provided a formal grading system for the strength of recommendations for all the medical conditions in their apps. All apps had offline access except DynaMed and Micromedex and 5-Minute Clinical Consult. Certain features, such as offline access and evidence grading, may not be widely used in these apps. The lack of editorial quality and transparency in reporting the apps' evidence-based methodology remained visible. Smartphone apps that provide point-of-care information summaries must provide evidence-based information. Healthcare professionals can use the findings of the systematic assessment to more confidently choose a smartphone app that offers point-of-care information summaries for evidence-based information in practice. Additionally, by using appropriate point-of-care information summaries, primary care clinicians may be able to retrieve clinical information at the point of care more quickly, even without internet connectivity. Systematic review Submitted paper: Lee, M., Smith, H.E., Tudor Car, L. Effectiveness of educational interventions for improving information literacy in healthcare professionals: a systematic review. Health information and libraries journal. Finally, the systematic review on the effectiveness of information literacy training for clinicians included ten studies mainly comparing the effectiveness of lectures and bedside education to lectures or no intervention. There was evidence for improved attitude towards the intervention favouring lecture with self-directed learning intervention over lecture, bedside education, and computer-assisted self-directed learning (RR:1.14; 95%CI 1.06-1.23; N=2 studies; 1,064 participants; I2=0%; moderate certainty evidence). The effect of the interventions on other primary outcomes, such as healthcare professionals' knowledge, skill, satisfaction, and behaviour change, was unclear due to limited, poorly reported findings. The evaluated interventions did not leverage digital technology in delivering educational interventions or as part of the information literacy intervention. As shown in qualitative study 2, since several primary care clinicians struggled with evidence-based medicine concepts, there is a need for additional training or a refresher in applying evidence in clinical practice. This PhD project has contributed to information literacy and evidence-based medicine and practice. The findings in the scoping review provided a broad overview of smartphone usage among doctors in the literature. They pointed to the need for hospitals or the government to enact legislation to guide smartphone usage among healthcare professionals. The results from the qualitative studies showed the growing and diverse adoption of smartphones in clinical practice and point to the need to address barriers primary care clinicians in Singapore face when seeking information, such as lack of information access due to no internet and limited information literacy. For example, this could be addressed through information literacy training and the provision of offline information resources to mitigate internet instability. The systematic assessment of apps can be used to inform healthcare organisations, healthcare professionals’, and other stakeholders’ choice of smartphone app-based point-of-care information summaries. Additionally, systematic assessment findings can be employed by software developers when developing features and functions of future tools. Finally, the findings from the systematic review showed the need for more robust evaluation in this area and effective up-to-date information literacy training that could incorporate digital tools in the delivery of intervention and access to information. The projects adhered to the principles of evidence-based medicine, drew on the body of knowledge for direction, and generously added to it. All provided data, findings, and conclusions were produced using a rigorous methodology and were done ethically and morally.