Maggio Lauren A, Aakre Christopher A, Del Fiol Guilherme, Shellum Jane, Cook David A
Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.
Division of General Internal Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, United States.
J Med Internet Res. 2019 Jul 25;21(7):e13315. doi: 10.2196/13315.
Clinicians use electronic knowledge resources, such as Micromedex, UpToDate, and Wikipedia, to deliver evidence-based care and engage in point-of-care learning. Despite this use in clinical practice, their impact on patient care and learning outcomes is incompletely understood. A comprehensive synthesis of available evidence regarding the effectiveness of electronic knowledge resources would guide clinicians, health care system administrators, medical educators, and informaticians in making evidence-based decisions about their purchase, implementation, and use.
The aim of this review is to quantify the impact of electronic knowledge resources on clinical and learning outcomes.
We searched MEDLINE, Embase, PsycINFO, and the Cochrane Library for articles published from 1991 to 2017. Two authors independently screened studies for inclusion and extracted outcomes related to knowledge, skills, attitudes, behaviors, patient effects, and cost. We used random-effects meta-analysis to pool standardized mean differences (SMDs) across studies.
Of 10,811 studies screened, we identified 25 eligible studies published between 2003 and 2016. A total of 5 studies were randomized trials, 22 involved physicians in practice or training, and 10 reported potential conflicts of interest. A total of 15 studies compared electronic knowledge resources with no intervention. Of these, 7 reported clinician behaviors, with a pooled SMD of 0.47 (95% CI 0.27 to 0.67; P<.001), and 8 reported objective patient effects with a pooled SMD of 0.19 (95% CI 0.07 to 0.32; P=.003). Heterogeneity was large (I>50%) across studies. When compared with other resources-7 studies, not amenable to meta-analytic pooling-the use of electronic knowledge resources was associated with increased frequency of answering questions and perceived benefits on patient care, with variable impact on time to find an answer. A total of 2 studies compared different implementations of the same electronic knowledge resource.
Use of electronic knowledge resources is associated with a positive impact on clinician behaviors and patient effects. We found statistically significant associations between the use of electronic knowledge resources and improved clinician behaviors and patient effects. When compared with other resources, the use of electronic knowledge resources was associated with increased success in answering clinical questions, with variable impact on speed. Comparisons of different implementation strategies of the same electronic knowledge resource suggest that there are benefits from allowing clinicians to choose to access the resource, versus automated display of resource information, and from integrating patient-specific information. A total of 4 studies compared different commercial electronic knowledge resources, with variable results. Resource implementation strategies can significantly influence outcomes but few studies have examined such factors.
临床医生使用电子知识资源，如Micromedex、UpToDate和维基百科，以提供循证医疗服务并进行床边即时学习。尽管这些资源在临床实践中得到了应用，但其对患者护理和学习成果的影响尚未完全明确。全面综合有关电子知识资源有效性的现有证据，将指导临床医生、医疗系统管理人员、医学教育工作者和信息专家就其购买、实施和使用做出循证决策。
本综述的目的是量化电子知识资源对临床和学习成果的影响。
我们检索了MEDLINE、Embase、PsycINFO和Cochrane图书馆中1991年至2017年发表的文章。两位作者独立筛选纳入研究，并提取与知识、技能、态度、行为、患者影响和成本相关的结果。我们使用随机效应荟萃分析来汇总各研究的标准化均数差（SMD）。
在筛选的10811项研究中，我们确定了2003年至2016年间发表的25项符合条件的研究。共有5项研究为随机试验，22项涉及执业或培训中的医生，10项报告了潜在的利益冲突。共有15项研究将电子知识资源与无干预措施进行了比较。其中，7项报告了临床医生的行为，汇总SMD为0.47（95%CI 0.27至0.67；P<.001），8项报告了客观的患者影响，汇总SMD为0.19（95%CI 0.07至0.32；P=.003）。各研究间的异质性较大（I>50%）。与其他资源相比（7项研究，不适合进行荟萃分析汇总），使用电子知识资源与回答问题的频率增加以及对患者护理的感知益处相关，对查找答案的时间影响各异。共有2项研究比较了同一电子知识资源的不同实施方式。
使用电子知识资源对临床医生行为和患者影响具有积极作用。我们发现电子知识资源的使用与临床医生行为改善和患者影响之间存在统计学上的显著关联。与其他资源相比，使用电子知识资源在回答临床问题方面成功率更高，对速度的影响各异。对同一电子知识资源不同实施策略的比较表明，允许临床医生选择访问资源相对于自动显示资源信息以及整合患者特定信息具有益处。共有4项研究比较了不同的商业电子知识资源，结果各异。资源实施策略可显著影响结果，但很少有研究考察这些因素。
