Project Definition

Lay summary

Computer-based reminder systems have been proven to be effective mechanisms for improving clinical practice in a variety of areas, including trauma care. They remind health professionals of the best practices to follow for many clinical conditions. Finding new ways to make sure that the people who will actually use the reminders are involved in designing them, introducing them and assessing them will make them more effective. This meeting will bring researchers and others involved in the field of trauma care together to develop a wiki-based reminder system and a mechanism (designed using a behavioural theory) to introduce this system among emergency health care professionals. A wiki is an innovative social media application that allows many users to collaboratively write documents. A reminder system is a computer-based system that contains documents that help clinicians remember the best medication to prescribe or the best diagnostic test to order. Adding wiki features to a reminder system has the potential to create a powerful and low-cost reminder system that users can update and modify as new evidence becomes available. Over a 1.5 day meeting, researchers, trauma experts, social media experts, patient representatives and decision makers from Canada and elsewhere will collaborate to: 1) review the current state of knowledge about how existing wiki-based reminder systems work in practice; 2) select a theory-based mechanism with practical strategies for introducing a wiki-based reminder system; 3) develop a research plan for evaluating how successful the system is; and 4) give feedback about barriers to its success. Meeting activities will follow a process for designing such mechanisms called intervention mapping, and will involve expert presentations, round-table discussions, small-group workshops, and plenary sessions in which the conclusions of each small group are summarized. The meeting will strengthen existing partnerships and serve as a platform for designing, introducing and assessing a theory-based mechanism that will correspond to the needs of all those interested in improving trauma care.

Introduction

Health professionals’ failure to implement best practices in clinical practice is costing Canadians their health [1, 2]. The problem is far from anecdotal: 50% of patients with major traumatic injuries do not receive recommended care [3-8]. In the province of Quebec, a recent study by André Lavoie funded by the Canadian Health Services Research Foundation [September 2010, personal communication with authorization], found that many trauma practices in Quebec’s emergency departments (EDs) are substandard because they underuse proven therapies. Studies in several countries have identified adverse events, including death, that occur in emergency and trauma care because of this failure to adopt best practices [9-12]. These figures make it clear that finding ways to promote best practices in trauma care has become urgent, both in Quebec and Canada.

Various aspects of emergency and trauma care can be barriers to the exercise of best practices [5]: unstable patients, incomplete histories, time-critical decisions, concurrent tasks, the involvement of many disciplines, and the extended hours frequently worked by junior personnel. Reminders (e.g. care protocols, order sets, treatment algorithms) are knowledge tools [13] that can improve intuitive decision making and help professionals implement best practices [14]. Finding new and innovative ways to involve end-users in designing, implementing, and evaluating reminder systems could increase their use and their impact on health outcomes. Systematic reviews indicate that computer-based reminders are effective interventions for fostering best practices in a variety of clinical areas [15-24], including acute care, where they improve process of care outcomes [25]. This said, emergency and critical care professionals have rejected many reminder systems on the grounds that they are slow, incompatible with work processes, poorly adaptable to local circumstances, difficult to access and/or costly to implement [26-32]. Given these barriers and the increasing pace at which new knowledge is being produced, there is now an urgent need to develop knowledge translation (KT) strategies that boost health professionals’ use of computer-based reminders in emergency and trauma care.

Web 2.0 applications (or social media) allow social networking, participation, empowerment of individuals to disseminate knowledge (a process that Eysenbach calls ‘apomediation’ [33], open sharing, and collaboration). Collaborative writing applications [34, 35] are a category of social media whose popularity has surged in recent years [33, 34, 36, 37]. Although no two applications are identical, all consist of software that allows users to create online content that anyone with access can edit or supplement [38]. The best known of these is the wiki, probably because Wikipedia has 365 million visitors per month and is the sixth most popular website in the world [36]. Wikis can be open (viewed and edited by all, like Wikipedia) or closed (viewed by all, but edited only by those who have access). Organizations can also house wikis in their intranet that can only be viewed by those who have permission. Several healthcare organizations have begun using wikis as centralized knowledge management systems that allow authorized personnel to edit and share important information [39, 40].

Conceptual framework

Within CIHR's knowledge to action framework, a wiki-reminder system accomplishes three different KT processes (see Appendix 2). First, a wiki acts as a repository for storing various knowledge tools (e.g. protocols, care pathways, order sets). Second, it stores the tools as wiki pages, allowing users (e.g. clinicians, decision makers) to update and adapt them to local circumstances while respecting the essentials of the original protocol. Third, wikis empower users to sustain this knowledge implementation because they are open, easy to access and easy to edit. Using the wiki as a centralized knowledge management tool, all trauma centers could collaborate on a large scale to share protocols. Such a wiki would enable centers that excel to share best practices with others, benefitting the entire Canadian trauma system. This wiki could also help standardize protocols based on best evidence. In addition, a wiki could facilitate the creation of protocols with other health professionals, thus permitting an inter-professional approach to promoting excellence in care. Eventually we foresee that a wiki could enable us to include patients’ values and preferences in developing knowledge tools (e.g. patient handouts, decision aids) that address their needs.

Earlier work

This research team is currently pursuing an innovative knowledge translation (KT) research program on the use of wiki-based reminders to promote best practices for the care of trauma patients in Quebec. Funded by the Fonds de recherche du Québec – Santé, this research program has led to the development of a survey to assess emergency healthcare professionals’ intention to use wiki-based reminders. The published protocol for this survey, which was based on the Theory of Planned Behaviour, is “highly accessed” [41]. We published the qualitative results of the study in an article about the most influential determinants (salient beliefs) associated with professionals’ intention to use a wiki-based reminder at the point of care [42]. This article presents the behavioural, normative and control beliefs most frequently reported by emergency physicians (Figures 5a-c) and allied health professionals (Figures 5d-f). Based on these salient beliefs, we created two validated surveys, one for emergency physicians (EPs) and another for allied health professionals (AHPs), that we are currently using to measure their intention to use a wiki-based reminders in trauma care. Using these questionnaires, our team has also recently conducted a pre and post evaluation of the intention of healthcare professionals to use a wiki-reminder system developed by the Emergency Department at the CSSS Alphonse-Desjardins (http://goo.gl/YWTBV). To assist this evaluation, we also created a YouTube video (http://goo.gl/JqNk3) that presents the wiki concept adapted to the local context.

This research program has also produced a scoping review [45] on the use of wikis and other collaborative writing applications (CWAs) tools in health care, with the aim of giving knowledge users a summary of the evidence about the most effective, safe and ethical use of CWAs in health care. Our review identified both positive and negative impacts of CWA use and made an inventory of the barriers and facilitators to their adoption in health care. The review also identified the need to conduct a robust prospective clinical trial to assess the impact of a wiki-based KT intervention, an intervention we will design using this project grant (Appendices 3 and 4). Before conducting such a trial, we must find solutions to some of the identified barriers to using wikis as a healthcare intervention. Among the barriers that need to be addressed are the reliability and quality of information contained in the wiki-reminder system.

The Purpose (Mission)

The mission of this national and international collaboration is to:

  1. Bring together the resources and expertise needed to develop a theory-based intervention to increase trauma care professionals’ use of wiki-based reminders promoting best practices in trauma care.

  2. Lay the foundation for a strong and sustainable collaboration between researchers and stakeholders involved in improving trauma care.

These are the specific objectives we want to meet

The specific objectives of this initiative are:

  1. Review the current state of knowledge and identify gaps in knowledge in the implementation of wiki-based reminder systems.

  2. Select a theory-based intervention to promote the use of a wiki-based reminder system and the practical strategies to implement the intervention.

  3. Develop a research plan for evaluating the implementation of the selected theory-based intervention.

  4. Using our current wiki-based reminder system experience as an example (CSSS Alphonse-Desjardins), solicit feedback about the potential barriers our team could face when they implement its use on a wider scale.

  5. Explore how to ensure that high-quality information is shared within the planned wiki-based reminder system.

Planned activities

A 1.5-day workshop will be organized in Quebec City that will bring together researchers, trauma experts, social media experts, patient representatives and decision makers from Canada and elsewhere. Prior to holding this meeting, we will create a Google Sites wiki. This wiki website will be used as our own central knowledge management system for the duration of the meeting. It will contain all the important information about the meeting: agenda, list of participants with short biographies, contact information and photos, the meeting objectives, preliminary readings and a discussion forum. Participants will be invited to view a short YouTube tutorial before they come to the meeting on how to use this wiki website, and we will invite participants to practise using the wiki by conducting a pre-conference needs assessment. We will also briefly present Google Docs to the group to remind them of the main features that can be used for writing collaboratively during the conference.

The agenda and meeting activities (see agenda in Appendix) will follow a process that is based on intervention mapping, a framework for developing theory-based health promotion programs [43, 44]. Our meeting topics will mirror the six steps of the process (see Appendix 5): 1) needs assessment and listing of main determinants associated with using a wiki-based reminder (already performed by our survey and scoping review [42, 45]); 2) definition of intervention objectives based on our earlier study analyzing clinicians’ needs and determinants of use; 3) selection of theory-based behaviour change techniques using Michie et al´s matrix (Appendix 6) which maps potential techniques onto behavioural determinants [46]; 4) listing practical components of the intervention program; 5) adoption and implementation of the program; and 6) preparation of the evaluation plan.

After initial words of welcome and a brief presentation of the meeting plan, we will start the first day of the meeting with a round-table discussion in which all participants introduce themselves and state their expectations for this meeting. The principal investigator will then present the main findings of his ongoing research program highlighting the main determinants of healthcare professionals' intention to use a wiki-based reminder system and the potential barriers that need to be addressed before moving forward. He will also present the prototype wiki-based reminder system in use at the CSSS Alphonse-Desjardins and its pre/post evaluation results. After this presentation, participants will be invited to express their own needs for a wiki-based reminder system in round-table discussions. They will also be asked to identify barriers they perceive to adopting the proposed wiki-based reminder system. Thereafter, an expert in information and communication technology adoption (Marie-Pierre Gagnon) will present on the importance of adopting a theory-based strategy to implement our wiki-based reminder system. A round-table discussion will follow to select the most important behaviour determinants to target in our intervention program objectives. Marie-Pierre Gagnon will then help the participants decide which behaviour-modifying intervention might best address the behaviour determinants selected. In the afternoon of the first day, a human factors engineer (Holly Witteman) will present user design principles that could help refine the current wiki-based reminder system and guide the design of the implementation intervention. Following this presentation, an interactive session given by international social media experts (Tom van de Belt and Gunther Eysenbach) will review various technical aspects of wikis. This will stimulate a discussion about the changes to the wiki-reminder system we will need to implement if we are to adapt wikis for use as a reminder system in trauma. The first day will finish with a series of presentations given by various knowledge users interested in implementing a wiki reminder system. Thus, a representative of the Trauma Association of Canada (Sandro Rizoli), the Institut national d'excellence en santé et services sociaux (Jean Lapointe), clinical experts and researchers (Alexis Turgeon/François Lauzier/Eddy Lang), an expert in nurses' adoption of information technologies (Marie-Pierre Gagnon) and patient representatives (Marie Robert and Nathalie Laroche) will present perspectives to consider in our planned implementation. In order to continue building links within the team, a restaurant in Quebec City will be reserved for the evening to continue networking and informal discussions over a meal.

The second day of the meeting will begin with a brief summary of the discussions from the first day and will continue with a small group workshop to discuss the themes, scope, sequence, participants and materials needed to implement our planned intervention. This will be followed by two plenary presentations given by a wiki expert (Tom van de Belt) and trauma quality of care experts (Lynne Moore and Tom Stelfox) about the different processes and patient-oriented outcomes that could be used to measure the impact of our intervention. These two presentations will stimulate our discussions during a final small-group workshop to discuss the overall evaluation plan for a future cluster-randomized trial.

Throughout the whole 1.5-day meeting we will invite participants to exchange and provide feedback in multiple ways. First, we will encourage all participants to provide verbal feedback by intervening at any moment to offer their thoughts and/or ask questions. All interventions will be recorded and transcribed by a professional transcriptionist. A research assistant will moderate our Google Site and update it throughout the meeting so that participants can always have a summary of the ongoing discussions. We will ask participants to use Google Docs to provide written feedback for certain of the group activities. We will also use this innovative collaborative writing tool to write the final report for this meeting.

This is how our team will gain

The meeting will consolidate existing partnerships and lay the foundation for a grant application to the Canadian Institutes of Health Research (CIHR) Partnerships for Health System Improvements program. We expect the meeting to serve as a platform for the design, implementation and evaluation of a theory-based intervention that will give the many stakeholders involved a solid foundation for developing a successful quality improvement project. Very few researchers in KT are exploring the use of collaborative writing applications such as wikis, let alone using a theory-based approach to explore these innovative solutions. Wikis are open-source and free software that require very few resources to set up, giving them the potential to be a low-cost mechanism available to all for improving and sustaining the use of evidence at the point of care. Not only will this meeting generate highly relevant results for the knowledge users involved, it will also support other health organizations planning to use collaborative writing tools such as wikis. In particular, our reinforced partnerships with INESSS, the Trauma Association of Canada and two patient organizations will serve as the basis for a nation-wide initiative to improve the quality of trauma care and will ensure that results generated will be relevant for patients across Canada. Ultimately, we foresee that our findings will benefit knowledge users in healthcare organizations throughout the world, not least in developing countries where clinicians are most likely to value applications that share free, reliable health information. We intend to publish a manuscript about this meeting and publish an account of our experience of using wikis as a knowledge management system to support the running of meetings of this complexity. This manuscript will be submitted to an open-source journal like the Journal of Medical Internet Research. Finally, each organization involved as a knowledge user has committed to disseminating a brief executive 3-page report translated in French and English summarizing the main conclusions of the meeting on their respective websites. We will also publish a lay summary of this report with the help of a professional writer. The YouTube videos and tutorials used for preparing the meeting will also be disseminated freely and links to these videos will be posted on the different knowledge users websites. We intend to disseminate the findings and conclusions of this meeting through different social media platforms like Twitter and on the Bulletin e-Veille on innovations in the health care that the Réseau de recherche en santé des populations disseminates. Presentations to publicize this initiative will also be made at different professional conferences.

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