FACULTY OF MEDICINE
Continuing Medical Education
TRW Building
3280 Hospital Drive NW
Calgary, Alberta Canada T2N 1N4
T +1.403.970.6742
F +1.403.210.9247
E topps@ucalgary.ca
ucalgary.ca
DynIA: Dynamically Informed Allegories
A knowledge translation project, combining webinars, virtual patients and
asynchronous discussion around clinical practice guidelines on chronic pain.
Co-Principal Investigators: Paul Taenzer and David Topps
Co-Investigators: Heather Armson, Eloise Carr, Rachel Ellaway, Cathlin Mutch, Ashi
Mehta
Funding: Canadian Institutes of Health Research (CIHR)
Parent organizations: University of Calgary and McMaster University
Project dates: Jan 1st 2013 – March 31st, 2014.
Theme 4: Lay Summary
An important strategy for improving population health is to use what we learn from
medical research in our patient care. One approach to this is using the highest quality
medical research to make recommendations and guide healthcare providers in deciding
how to diagnose and treat their patients. These recommendations form the basis of
healthcare tools that are called clinical practice guidelines.
Theme four focused on strategies for increasing the uptake of clinical practice guidelines on
low back pain and headache into community-based care. Theme four researchers
collaborated with guideline developers in Alberta at the Institute of Health Economics and
an organization called Towards Optimize Practice (TOP) that is sponsored by the Alberta
Medical Association and the Alberta Ministry of Health (Alberta Health and Wellness).
The research team first looked at what is already been known about uptake of guideline
recommendations for chronic pain. This process involved going back to original research
from around the world. Research librarians and scientists found 19 scientific papers that
are relevant. Taken together, these studies indicated that the best approach to improving
uptake of chronic pain guidelines into community care is to present them to care providers
in special interactive educational settings where they are able to discuss the
recommendations approaches with the educators.
Theme four then went on to test this approach in the study of using an interactive
educational workshop focused on the low back pain guideline. The study was conducted in
collaboration with researchers from the University of Calgary and the University of Alberta.
The workshop presenters were an expert team of physicians, physiotherapists, nurses and
psychologists that traveled to the offices of the community healthcare providers. This study
showed that the providers’ knowledge of low back pain increased after the workshop.
When the medical records were examined, the researchers were unable to detect changes
in how care was provided. This was a small study involving 24 providers. The researchers
concluded that a larger study may confirm the increase in provider knowledge and detect
changes in care.
An important advance in healthcare is the use of computerized medical records.
Computerization also provides an opportunity for healthcare providers to access relevant
health information during their time with the patient. Theme four researchers collaborated
with the Department of Family Medicine that McMaster University to develop a tool to help
community caregivers use the recommendations from clinical practice guidelines while
they are in the office with patients. This tool called the McMaster Pain Assistant has
undergone successful usability testing and is now being tested in the community to see if
using the tool leads to increases in knowledge and decisions that reflect the guideline.
Rural physicians face important challenges in accessing medical education. In the past they
would have to leave their practices and travel to a distant site to learn. Theme four
researchers collaborated with the Department of Continuing Medical Education at the
University of Calgary to explore a distance learning approach using Internet-based
webinars and “virtual patients” that are designed to teach about the guidelines and how it
might affect their care. This preliminary study demonstrated that rural physicians
appreciated being able to access high quality medical education where they can interact
with experts without having to travel. They found the sessions and the virtual patients
highly engaging and realistic. Only small changes were shown in management of the virtual
patients through the case series. Detailed analysis of practice patterns showed participants
to be very conformant with clinical practice guideline recommendations.
Theme 4: 1) Study Objectives/Research Questions
Theme four: “Partnering with the Alberta HTA Chronic Pain Ambassador Programme”
undertook of four distinct studies all of whom were related to knowledge translation to
primary care providers for guideline implementation. The research questions for each
project are described below.
We undertook a systematic review of the research literature on knowledge translation for
guideline implementation for both primary care providers and for patients. The objectives
were to determine the effective strategies for knowledge translation from the world
literature on guideline implementation for these populations.
We also undertook a preliminary study of an interprofessional interactive workshop to
engage primary care providers on how the guideline recommendations could be
implemented in their practices. We sought to answer the following questions: 1) Does
participating in the workshop improve physician knowledge of best practice in low back
pain assessment and management 2) Do physician practice patterns demonstrate
improved compliance with evidence-based guidance and 3) Is it feasible to recruit for a
larger randomized trial to assess the impact of the workshop using this study design?
We partnered with the Department of Family Medicine of McMaster University to develop a
computerized decision-support (CDSS) tool for the OSCAR electronic health record. This
tool is designed to support multidisciplinary pain providers in conducting and
documenting primary care chronic pain visits. The tool has guideline recommendation
based advice as well as easily accessible patient education handouts and videos,
standardized practice relevant measures for screening for clinical “red flags” and risk
factors for chronicity as well as for tracking patient progress. The tool incorporates the
pharmacological guideline for neuropathic pain as well as the Alberta low back pain
guideline. Funding for the neuropathic component and the outcome study (study four) are
provided through a grant from the Lawson health Institute from the University of Western
Ontario. Four projects have been undertaken, including interviews and focus groups with
providers and with patients to answer the following research questions: for providers;
what are the challenges in treating patients with chronic pain, what are the challenges in
using electronic health records, what would you like to see in a chronic pain CDSS? For
patients; how could the electronic health record improve your interaction with your
primary care provider, would you like to contribute to and have access to the electronic
health record? The third study addressed the usability of the iterative drafts of the
decision-support tool to identify how users were interacting with the draft CDSS. The final
study that is currently underway utilizing funding from another grant is exploring the
impact of the tool on provider knowledge and practice patterns and addresses the
question: does using the computerized decision-support tool lead to increased knowledge
and compliance with the guideline recommendations?
We also collaborated with researchers from the University of Calgary Department of Continuing Medical
Education in a pilot study exploring the feasibility of using interactive webinars and virtual patients and
secured internet discussion forums of low back pain and headache as a strategy for providing distance
education regarding the guideline recommendations. The project explored the following research
questions: 1) are these feasible tools for promoting evidence-based practice in primary health care; 2)
are these tools and acceptable for physicians for improving clinical management in chronic pain
conditions ; 3) will the tools lead to improvements in knowledge, clinical reasoning skills and confidence
in managing primary care patients with headaches and low back pain.
Theme four: Methods & Measures
The systematic review of KT strategies for chronic pain was undertaken by a health
technology assessment specialist at the Institute for Health Economics and used
standardized methodologies for the literature search and quality appraisal. Clinical
expertise for reviewing the relevance of potential research studies was provided by
members of the theme four research team.
The preliminary study of the interactive workshop recruited 21 physicians from four
Alberta practices and used a pre-post single group experimental design. Outcome measures
included a standardized knowledge survey of assessment and treatment of low back pain, a
chart audit of practice behaviours and the measure of satisfaction.
The needs assessment studies of providers perceptions of the challenges of treating chronic
pain and of using the electronic health record and desirable characteristics of a
computerized decision-support tool as well as the patient needs assessment regarding
potential benefits of such a tool used a structured interview format for both individual
interviews and focus groups. Qualitative analysis was undertaken to determine the
recurrent themes in the interview transcripts. 21 clinicians and 12 patients participated.
The usability assessment study involved 12 clinicians who were observed using the draft
CDSS over two iterations of development. A System Usability Scale (SUS) was used to
obtain a numerical rating of their impressions.
The feasibility study of interactive webinars and virtual cases also used a pre-post design
with the knowledge assessment measurement derived from the responses to the virtual
cases. We used an emerging methodology called “script concordance testing” which has
been used in the past in medical education to evaluate students’ clinical reasoning by
comparing participants and experts in their decision-making styles. Satisfaction with the
webinars and virtual cases was also collected.
The study recruited 22 physicians from three rural Alberta communities. Outcome
measures included pre- and post- structured online surveys, a focus group discussion with
each site visit, and detailed analytics around clinical reasoning (using the virtual patient
software). Qualitative analysis conducted for recurrent themes around barriers to
implementing CPG recommendations, driven by virtual patient case specific material.
Theme 4: Key Findings
The systematic review to assess the effectiveness of knowledge translation studies for
chronic pain used a comprehensive search strategy of electronic databases, the gray
literature and hand journal searches to identify appropriate RCTs and controlled studies.
19 studies were included. Interactive education for health providers showed positive
affects regarding provider knowledge and patients’ functional capacity. Benefits of KT
strategies for other health providers and for patients were less clear.
The low back pain workshop preliminary study found that physician knowledge improved
after the workshop. However the chart audit of physician practice behaviour was
inconclusive. Participating physicians found the workshops helpful and appeared to
increase knowledge however the significance of knowledge acquisition on practice is
unclear.
The focus groups for the CDSS study involved 21 clinicians and 12 patients. Clinicians
identified that a CDSS could facilitate continuity of care, provide a ‘backbone’ when feeling
pressured to prescribe narcotics as the CDSS could focus on guidelines and they
appreciated that the CDSS could provide longitudinal information for helping understand
how the patient’s pain had changed over time. Strategies to support the use of the CDSS
included having data entered in one spot populate appropriately in other areas, minimum
of “clicks” to manoeuvre through the chart and hyperlinks to other pertinent information
such as patient education materials and instructional videos. Patients felt that if clinicians
can easily access their history of pain management including medications that this could
result in better interaction with their providers.
The DynIA project involved 22 clinicians in a series of 3 webinars, 27 virtual patient cases
and an asynchronous discussion forum. There was tight integration between virtual patient
material and webinar content, which created a highly engaging set of activities. All of the
sessions ran over time, even though this cut into private time with no reimbursement.
Strongly positive qualitative comments were garnered about the challenging and realistic
nature of the case and webinar material. Participants were highly committed to completing
pre-webinar case material, which is highly unusual for CME events. Case management of
the virtual patients correlated closely with expected pathways as suggested by the clinical
practice guidelines in most areas. An unanticipated benefit of this project was the
development of a powerful, scenario-based set of educational activities, with detailed
underlying analytics that will facilitate further findings.
Theme Four: Implications and Actual or Potential Impact
Theme four has two likely impacts.
The first being the publication of the systematic review identifies the “state of the science”
for knowledge translation and chronic pain. Individuals and agencies will find this review
an important resource in designing their knowledge translation strategies for primary care
providers. The preliminary study of the interactive education workshop is consistent with
the systematic review and sets the stage for further work in this area.
The computerized decision-support study and the study of webinars and virtual patients
both suggest that these innovative ‘technology enhanced’ strategies for knowledge
translation are feasible for use with primary care providers. The virtual patients provide a
means by which clinical reasoning can be explored with detailed analytics. These studies
are preliminary and encourage further research into these approaches.