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The Role of Knowledge-Based Information

JCAHO has identified expert knowledge-based information as vital to an organization's ability to provide patient care. Knowledge-based information is commonly referred to as "the literature." Although knowledge-based information must be included in the institution-wide planning addressed in standards IM.1 - IM.6, IM.9 specifically addresses the process related to the management of knowledge-based information.

Knowledge-based information supports clinical decision making, continuing education of staff, administrative planning and management, performance assessment and improvement, patient and family education, and research. Systems, resources and services are all necessary to effectively and efficiently manage knowledge-based information.

Systems refer to the structures that are needed to identify, locate, and control knowledge-based information, i.e., electronic and paper-based catalogs, networks, consortia, thesauri, controlled vocabularies, and standard nomenclatures. Resources are, of course, the information sources, i.e., journals, books, audiovisuals, databases and other electronic sources, practice guidelines, and patient education materials.

Although systems and resources are important, services are the most important factor in meeting organizational needs for knowledge-based information. Library and information services provided by professional librarians are critical to the organization's ability to not only respond to information requests, but also provide information in advance by anticipating information needs and systematically linking current, gold standard evidence from the literature with health care processes.

Let's look at a case example demonstrating how a professional librarian could systematically link knowledge-based information with a clinical process. In this case example, the librarian is a member of a clinical indicator development team. As you know, clinical indicators are based on expert opinion validated by evidence from the literature. Based on their analysis of aggregate patient data and assessment of the medical center's needs, this team selected the indicated statement "Patients with a diagnosis of diabetes mellitus should not require admission to the hospital for complications of diabetes." The librarian worked with the team to precisely define the indicator terms and to determine what information was required to affect the outcomes for this patient cohort.

With this knowledge, the librarian selected appropriate terms from a controlled vocabulary to address each complication referenced in the protocol. In this case, the librarian selected the term diabetic ketoacidosis, foot ulcer for interrupted skin integrity below the ankle, diabetic coma for hyperosmolar coma, blood glucose metabolism in combination with diabetes mellitus to get at the concept of poor diabetic control, and diabetic retinopathy. Using these terms, the librarian designed several search strategies to identify information on the following concepts in relation to each complication: patient outcomes, risk factors, therapeutic interventions, hospital admissions, practice guidelines, and ambulatory care. In addition to the concept refinement used to get information from clinical databases, the librarian also searched specialized databases to address other aspects of the problem, i.e., assessment and evaluation, economic factors, and patient health information.

After doing an efficient search of the literature, the librarian selected the best of the relevant literature and applied rules of evidence to determine its validity. The librarian kept the indicator rationale in mind throughout the review process: Diabetes is a disease which accounts for substantial morbidity and hospitalizations. If these complications can be managed successfully in the ambulatory care environment, hospital admissions as the result of diabetes-related complications could be reduced. The librarian's review of the literature basically answered this question: What does the literature suggest are successful interventions to keep our patients out of the hospital?

The librarian highlighted salient information in the literature selected and sent a packet of highlighted articles to each team member. The packet included literature demonstrating interventions that were significantly successful in early diagnosis and management of diabetes in an outpatient population, as well as practice guidelines to serve as benchmarks in developing the indicator. In the future, the packets may also contain comparative data from external databases.

The librarian's review of the literature revealed some interesting patterns. The literature reported that diabetic neuropathy was often the underlying cause of interrupted skin integrity below the angle; the risk of retinopathy is closely related to neuropathy; and there is a link between glucose control and diabetic neuropathy. Based on this empirical evidence, the team recognized that diabetic neuropathy was an important complication which should be included in the indicator.

Following the development of the indicator, the librarian participated in other work groups which developed staff training and education and patient health education. To support staff education, the librarian prepared packets of information addressing early identification of diabetic complications and associated outcomes. To support patient health education, the librarian prepared packets of information addressing proper self-management of diabetes, i.e., articles, pamphlets, and video-cassettes on diabetic foot care for patients and their families.

Although this case example demonstrates the linkage of knowledge-based information with clinical indicators, the concept can be applied to any health care process. Health care providers will continue to face an exploding volume of knowledge-based information, rapid introduction of new technologies, deepening concern about burgeoning medical costs, and increasing attention to the quality and outcomes of medical care. The librarians' systematic linkage of knowledge-based information with health care processes will help health care institutions provide high quality cost effective health care.

This article reflects the authors' personal views and in no way represents the official view of the Department of Veterans Affairs or the U.S. Government.

Christiane Jones is the Chief, Library Service, VAMC Biloxi, MS; Terrie Wheeler is Chief, Library Service, VAMC Pittsburgh, PA; and Wendy Carter is the Director for Library Programs, VA Central Office, Washington, DC. Article is reprinted by permission from SEA Currents, the newsletter of the Southeastern/Atlantic Region, v. 12, n. 5, September/October 1994.