A comparative case study of two models of a clinical informaticist service

The two informaticist service projects described in this paper were part of a larger initiative aimed at promoting the use of research evidence in primary care, which was established by the North Thames Region R & D Implementation Group. An independent evaluation of the overall initiative was commissioned to run concurrently with the individual projects. The aims of the evaluation, which became known as RiPPLE (Research into Practice in Primary Care London Evaluation), were to document each project’s progress and the organisational context within which decisions were made, to identify common themes in the activities and experiences of all the projects and draw lessons about the process of implementing evidence in primary care, and to make policy recommendations at regional level.

To this end, the RiPPLE group (JH, TG, SR, CH) initially set out to establish a partnership with the project groups, offering their evaluator (JH) as an independent resource to assist with planning, communication, documentation, and evaluation. Emphasis was placed on assisting project teams to define their needs and design appropriate evaluation strategies, supporting and encouraging appropriate data collection, and identifying opportunities for collaborative work across the projects. The evaluator’s close involvement with the projects allowed the RiPPLE group to gain a thorough understanding of each one’s aims, circumstances, and progress, thus facilitating a case study approach. The main methods of data collection used to evaluate the informaticist service projects were

· Attendance at project steering group meetings (or equivalent)

· Attendance at other key meetings held by the project groups

· Building relationships with both project workers and steering group members and assisting with data collection for the projects’ internal evaluations

· Face to face or telephone interviews with participating clinicians who had used the informaticist service

· End of project interviews with key staff.

JH undertook the field work, sometimes accompanied by other members of the RiPPLE group, and made contemporaneous field notes of all meetings and contacts. Evaluation interviews were guided by a schedule developed collaboratively by the RiPPLE group but also allowed respondents to discuss issues they considered important. These interviews were audiotaped and subsequently transcribed. The RiPPLE group met at two-monthly intervals, at which the evaluator (JH) presented her accumulated raw data along with an interim interpretation, which was then considered and discussed by the group. Interim reports were also fed back periodically to the project groups.

The evaluator encouraged both project groups to take an interest in what the other was doing, exchange information informally, and explore possibilities for collaboration. Differences and similarities in approach were frequently discussed, which helped the project groups develop and articulate their distinctive approaches to providing a clinical informaticist service. Eighteen months into the projects the RiPPLE group facilitated a meeting between the two project groups, with the aim of sharing their experiences and exploring further the emerging key similarities and contrasts in their approaches. This prompted reflection by all parties, and the project groups subsequently provided written responses to the preliminary case study reports offered by RiPPLE. These were incorporated into the final analysis, and the paper presented here is the joint work of the RiPPLE group and representatives of both project groups.

Imperial College project

Origin of project bid

· Academic department of general practice

Aim as stated in original proposal

· To assess the feasibility and impact of using a vocationally trained general practitioner further trained as a clinical informaticist to promote evidence based practice in a defined group of general practices

Main objectives as stated in original proposal

· To establish guidelines for using the clinical informaticist

· To produce a costed package to be used by others

· To explore the knowledge and behaviour gap

· To develop a database of evidence based answers to clinical queries

· To train a cadre of primary care clinicians to pose questions

Staffing

· Part time general practitioner informaticist plus part time researcher and administrator. Both based in academic department of general practice.

Training and supervision of informaticist

· Intensive, one-to-one training by academic librarian in search strategies. Short courses on critical appraisal. Supervised by senior lecturer in general practice within highly rated academic department.

Key features of project

· Two stage project with pilot phase in two "innovator" health centres followed by definitive study with volunteers

· Strong research element from outset, to include several questionnaires completed by participants and stakeholders

· Relatively fixed project plan, which did not adapt well to changing circumstances (such as loss of "product champion")

· Few local links

Basildon project

Origin of project bid

· Joint bid from individual general practitioner, health authority, and community trust

Aim as stated in original proposal

· To explore the effect of employing a clinical informaticist to work in primary care

Main objectives as stated in original proposal

· To stimulate questioning behaviour in primary care clinicians

· To research the questions posed

· To provide information in a concise and understandable format

· To help clinicians implement changes in practice

Staffing

· Initially, one part time general practitioner informaticist based in a local practice and provided with administrative support. Subsequently, four local general practitioners and a nurse working two sessions each in different localities

Training and supervision of informaticist

· Short courses on searching, critical appraisal, basic information technology, and presentation skills. After six months, he was described as having attained "a reasonable level." Supervised by project leader (local general practitioner)

Key features of project

· Planned to use a developmental approach working with enthusiasts and using these to get others on board

· Specific aim to engage nurses as well as doctors

· No formal academic links

· Strong local links and knowledge via project leader, plus active steering group, allowed project to respond to changing environmental conditions and take advantage of opportunities as they emerged