The Practice of Informatics
Viewpoint Paper j
Evolution of a Mature Clinical Informationist Model
NUNZIA B. GIUSE, MD, MLS, TANEYA Y. KOONCE, MSLS, REBECCA N. JEROME, MLIS,
MOLYNDA CAHALL, MA, MSLS, NILA A. SATHE, MA, MLIS, ANNETTE WILLIAMS, MLS
A b s t r a c t
health care delivery and to integrating evidence and informatics at the point of care. To support evidence-based
practice, Vanderbilt University Medical Center’s Eskind Biomedical Library (EBL) introduced the role of clinical
informationist, an information specialist with sufficient knowledge and insight to function as a true partner in the
health care team. To further disseminate evidence-based knowledge, the Vanderbilt University Medical Center’s
(VUMC) electronic medical record system and pathway development processes integrate advanced information
synthesis capabilities provided by clinical informationists. Combining clinical informationist expertise with informatics
tools is an effective strategy for delivering the evidence needed to support patient care decisions.
Achieving evidence-based practice will require new approaches to providing information during
j J Am Med Inform Assoc. 2005;12:249–255. DOI 10.1197/jamia.M1726.
Limited Clinical Time and the Demands of
The literature of information science and medicine is rife with
concerns about the exponential growth of available medical
information.1–5However, the demands of everyday practice
often preclude physicians from spending the time required
to address many questions that arise during patient care.
Lack of time echoes throughout the literature as one of the
main barriers to the practice of evidence-based medicine
(EBM).6–20As Davidoff and Florance21assert, ‘‘Physicians
don’t, and never will, have [one hour or more] to look for
the answers to most of their clinical questions themselves.’’
In addition to time constraints, Ely et al.7and other investiga-
tors identified the limited coverage of information resources
and lack of readily available syntheses of the voluminous pri-
mary literature as two major obstacles to successful evidence
seeking.22A recent Vanderbilt study supported these obser-
vations, finding limited ability of several synthesized EBM
information resources to address adequately a random sam-
pling of complex questions received from critical care
specialists and from clinical pathway development teams.23
Thus, research indicates that physicians often encounter mul-
tiple questions during daily practice,6,24–27yet many ques-
tions generated during patient care may never be pursued
Pressed for time and inundated by information, clinicians
are often unable to consult the plethora of evidence sources
necessary to answer a complex clinical question.32–34Para-
doxically, clinicians with inadequate time to keep up with
the literature face a growing demand for evidence-based
practice and its core tenet of ‘‘integrating individual clinical
expertise with the best available external evidence from sys-
Strategies to Integrate Information into
To address this problem, the Eskind Biomedical Library (EBL)
at Vanderbilt University Medical Center (VUMC) has devel-
oped several solutions to leverage the power of informatics
tools and the advanced evidence retrieval and appraisal skills
of librarians. These strategies, evolved from EBL’s devel-
opment of a clinical informationist model, center around
integrating expert information provision with informatics
systems. A clinical informationist is a professional member
of the healthcare team who focuses on the intersection be-
tween clinical care and the evidence base contained in the lit-
erature and in biomedical databases and resources. The
informationist acts as an expert in identifying and addressing
the complex evidentiary needs of the team.21,36–48
Affiliations of the authors: Eskind Biomedical Library, Department of
Biomedical Informatics, Vanderbilt University Medical Center,
Nashville, TN (NBG, RNJ); Eskind Biomedical Library, Vanderbilt
University Medical Center, Nashville, TN (TYK, MC, NAS, AW).
Supported in part by funding from the National Library of Medicine
(NIH Grant no. 5 R01 LM07849-02).
The authors thank Dr. Dario Giuse, for editing assistance, Shannon
Mueller for her work on the EBM Literature Request Service and
guidelines linkages, and Garad Megan Davis and Marcia Epelbaum
for their contributions to the Pathways project.
Correspondence and reprints: Nunzia B. Giuse, MD, MLS, Eskind
Biomedical Library, Vanderbilt University Medical Center, 2209
Garland Avenue, Nashville, Tennessee 37232-8340; e-mail: <nunzia.
Received for publication: 10/28/04; accepted for publication:
Journal of the American Medical Informatics AssociationVolume 12Number 3May / Jun 2005
Eskind Biomedical Library has implemented the information-
ist concept in its Clinical Informatics Consult Service (CICS)
and extended its reach via integration of CICS expert evi-
dence syntheses in VUMC’s electronic health record system.
In addition, EBL has leveraged both informatics tools and
the knowledge gained through CICS practice to link practice
guidelines to patient records and to incorporate evidence into
the creation of nursing care pathways. These solutions, de-
scribed in more detail below, represent novel means to facili-
tate evidence-based practice and the synergistic relationship
between EBL and medical informatics systems in the provi-
sion of evidence supporting patient care. Such strategies illus-
trate the value that intensively trained librarians can bring to
informatics and clinical care teams in supporting high quality
Toward a Clinical Informationist Model
An early iteration of the informationist concept was the clini-
consultant for patient care49,51–60but met with limited uptake
Current emphasis on cost-effective, high-quality care, with its
strong focus on applying evidence-based guidance to de-
crease medical errors, has fostered increased interest in and
demand for expert support to clinicians in accessing and ap-
plying the information contained in the clinical literature.
The approach taken by EBL assumes that (1) informationists,
equipped with extensive, relevant clinical knowledge and an
understanding of research practices, can deliver highly tar-
geted evidence in support of patient care and (2) the integra-
tion of evidence identified by human insight and intelligence
with informatics tools provides an efficient and effective
mechanism for making relevant information available when
and where clinical decisions are made.
Development of the Eskind Biomedical Library’s
Clinical Informatics Consult Service
Librarians are increasingly called upon as intermediaries be-
tween clinicians and the immense quantities of available in-
formation. To be effective in such roles, and to ease the
integration of evidence into the health care delivery process
and foster patient safety, librarians must become active mem-
bers of health care teams. Such immersion requires a collabo-
rative culture of learning and the willingness to expand
the library’s purview. At VUMC, a key development in the
EBL’s model of clinical librarianship was understanding the
vital importance of participating in an environment to com-
prehend it. This awareness led to the development of the
Clinical Informatics Consult Service (CICS)65,66and the train-
ing and infrastructure necessary to support the service.39,65–71
Cited by Davidoff and Florance21in 2000 as an innovative
‘‘informationist’’ model, the CICS is a novel approach to ad-
vancing clinical librarianship that mitigates many of the pre-
vious concerns raised about CML practice. The CICS
integrates librarians into clinical rounding teams as expert in-
formation providers, equipped with adequately deep back-
ground knowledge in both principles of clinical medicine
and information seeking. CICS participants can diagnose un-
expressed information needs as they occur during practice
and prepare relevant, balanced syntheses of the evidence
from the medical literature. Since the program’s inception,
the service has expanded to collaborate with 10 clinical teams.
Eskind Biomedical Library has focused on high-acuity hospi-
tal inpatient care units for CICS implementation. Such units
provide care for the most critically ill patients and generate
complex queries regarding information needs. These environ-
ments also encompass the potential for tremendous impact of
information on patient outcomes and clinician education at
highly meaningful points in time. Targeting these units allows
CICS informationists to work in some of the most challenging
environments and reach large numbers of clinicians. Resi-
dents and fellows undertaking specialty training in almost
all areas of clinical practice must now rotate through the hos-
pital critical care units associated with their specialties. The
EBL CICS program matches the interests of the librarian-
informationists (i.e., their enthusiasm for a particular area of
clinical practice) to the specific unit assigned to them. Motiva-
tion and enthusiasm figure significantly in determining the
success of a clinical informationist in a given field.
Just as the patient’s care team must accept caseworkers, nutri-
tionists, pharmacists, and other ancillary specialists as ac-
knowledged experts for them to play vital roles in patient
care, clinical informationists at Vanderbilt University Medi-
cal Center must establish themselves as legitimate partners
in the provision of high-quality health care. The CICS sup-
ports best clinical practices through providing, as Pearson ad-
and significance, representing the essence of the literature
in a balanced manner.
The CICS efforts required the library to develop a support-
ing culture of pervasive learning, training, and adapting of
skills. For more than a decade, EBL has devoted significant re-
sources to creating an environment that values and engages
in lifelong learning. The EBL training infrastructure supports
a diversity of roles for librarians, focuses on improved utiliza-
tion of resources, and has reallocated librarians from refer-
ence desk services to collaborations in the medical center
without adversely impacting the library’s budget.69To pre-
pare themselves for new roles, informationists build their per-
sonal knowledge bases in medicine and research design. They
enroll as students in Vanderbilt nursing and medical school
classes in areas such as biostatistics, anatomy,and physiology.
They also participate in case presentations on rounds, attend
clinical seminars, complete in-house learning modules, and
review journal articles and key textbooks in general medicine
and specialty areas.
As implemented in the clinical setting, CICS informationists,
ority level for results delivery with the clinical team. The type
and urgency of the need prompting the information request
determines the priority. Informationists provide results to
the initiating clinical team for acute information needs within
a period of several hours; intermediate priority queries within
two to three days; and queries with an educational or general
information emphasis within seven days.
To respond to information requests, informationists execute
and filter searches in a multistep cycle. First, they retrieve
a targeted initial group of articles and hand select the most
relevant items based on their ward experience–derived un-
derstanding of the question and the article’s content, thus,
GIUSE ET AL., Evolution of a Mature Clinical Informationist Model
taking into consideration the individual patient and hospital
unit situation. They then go beyond searching, by reading
and filtering the full text of the most appropriate articles,
highlighting passages that are relevant to the clinical case at
hand. When necessary, prior steps are repeated, including
searching for and reading additional articles. When search re-
sults yield multiple viewpoints, clinical informationists select
the best article representing each viewpoint—analyzing
study methodology and quality of execution as well as rele-
vance to clinical context. An analysis of viewpoints repre-
sented in EBL-authored evidence summaries indicated that
if librarians had stopped searching the literature after finding
the first relevant answer, additional relevant viewpoints
would have been missed for more than half the treatment-
Eskind Biomedical Library clinical informationists, in prepar-
ing their written reports, synthesize all of the highlighted
information from articles into a concise summary. Each
summary points out such factors as conflicting recommen-
dations in different articles, strength of the evidence, and
facts about a study that differ from the specifics of the clini-
cal case. This summary also includes a disclaimer, jointly
authored with the VUMC Office of General Counsel, advis-
ing clinicians to consult the full text of the articles (appended
to the summary report) before taking action and noting that
the summary is not intended to serve as a substitute for clin-
ical judgment. Ultimately, the clinician has the final respon-
sibility for determining whether the evidence applies to
a specific patient. Finally, the informationists present their re-
sults to the clinical team during rounds, addressing any ques-
tions about the evidence that arise during the discussion, and
identifying additional information needs as they arise.
Initial subjective evaluation of informationists’ performance
by clinical team members showed that clinicians consistently
rated clinical informationists’ ability to function in the clinical
vided, at thehighestlevels.65In addition, recent research, con-
Department of Biomedical Informatics faculty, indicates that
informationists identify literature relevant to complex clinical
questions as reliably as physicians trained in clinical research.
This work suggests that experienced clinical informationists
with training in information seeking, literature synthesis tech-
niques, and research design and biostatistics are adequately
equipped to function as surrogates for clinicians in selecting
relevant evidence for specific information needs.73
This advanced level of information filtering represents a cru-
cial component of the clinical informationist program at
VUMC and provides a concrete demonstration of the value li-
brarians bring to the clinical environment. EBL has also suc-
cessfully used this model for collaboration with biomedical
professionals in other settings, including fostering informa-
tion expertise among Tennessee public health officials and
aiding basic science researchers with focused application of
specialized molecular biology resources.74,75
Using Informatics Systems to Scale Library
In 2001, VUMC implemented the use of a more advanced ver-
sion of its electronic medical recordsystem foroutpatient clin-
ical practices. This web-based informatics system, StarPanel,
seamlessly integrated all aspects of a patient’s medical care
at the institution. The StarPanel approach took into consider-
ation, as a design principle, that unique patterns of communi-
cation represent core activities of each clinical team.76,77As
a ‘‘central information hub,’’ StarPanel brings into a single
interface data needed for outpatient (and most inpatient) clin-
ical decision-making.78The EBL recognized that its evidence-
related services might scale to reach a broader range of clinic
and hospital specialties (and care providers) through integra-
tion of such services into informatics tools such as StarPanel.
This insight, as well as lessons learned from CICS, informed
the development of a more mature clinical informationist
model that involves capture and delivery of evidence re-
quests via StarPanel.
Physicians in VUMC’s Adult Primary Care Center currently
use the existing secure, internal messaging feature of
StarPanel78to send patient care questions directly to EBL li-
brarians via ‘‘information baskets.’’ As part of the question
submission process, clinicians select from a list of priority lev-
els reflecting the urgency of the information request.
gent confidentiality measures as clinicians for accessing
patient information. Thus, the outpatient StarPanel informa-
tion queries arrive connected to the patient medical records
signed tothecasewithdirectaccess tothedetailsofthecase at
hand. Integration of the ‘‘outpatient evidence consultation re-
quest’’ function within the electronic health record system
overcomes the need for CICS librarians to be omnipresent in
less acute outpatient care delivery settings, and diminishes
the need for busy health care providers to collect and send
the patient-specific details necessary for librarians to provide
highly targeted evidence syntheses in response to questions.79
The Vanderbilt experience in this project has already demon-
strated that CICS librarian access to patient records affords
a clear advantage during the patient-specific information evi-
dence synthesis process. For example, in response to the clin-
ical query, ‘‘When should one operate on a patient with
hyperparathyroidism?’’ an EBL librarian examined the pa-
tient’s laboratory values (calcium, phosphate, and other
blood counts) and previous radiology reports as well as coex-
isting diagnoses and related notes from the patient’s endocri-
nologist regarding bone density results. Most importantly, the
librarian was able to extract from the literature the specific
recommendations for the patient’s relatively young age.
These details of the nature of the patient’s condition equipped
the librarian with a powerful means to customize the re-
sponse to the specific situation without requiring additional
time from the clinician making the request. This type of evi-
dence synthesis also becomes a permanent part of the pa-
tient’s medical record. Upon completion of the question, the
information specialist attaches the synthesized packet of in-
formation directly to the patient’s electronic chart for review
by members of the health care team.
Provision of relevant evidence-based information, even with
direct access to patient data, cannot be performed completely
‘‘behind the scenes.’’ This model thus incorporates lessons
learned about the importance of deep subject knowledge
and the benefits of domain immersion with inpatient teams.
Realizing that the existence of the EBM Literature Request
Journal of the American Medical Informatics AssociationVolume 12Number 3May / Jun 2005
button alone is not enough to generate continued use of the
service, EBL librarians make regular ‘‘drop-in’’ visits to the
clinic to maintain visibility and continue to develop trust as
well as collegiality with the clinicians. These periodic visits
also enable the librarian tostay currentwith clinicaltopics un-
der discussion in the outpatient setting.
Linking Evidence-Based Guidelines Within the
The inclusion of the EBM Literature Request service in the
StarPanel system provides a mechanism for addressing espe-
cially complex or uncommon patient problems. To support
management of common conditions, EBL has further inte-
grated evidence into StarPanel through the provision of links
to nationally recognized guidelines, dynamically generated
by mapping International Classification of Diseases, 9th
Revision, Clinical Modification Codes (ICD-9-CM) ,http://
relevant guidelines. Integration of evidence-based guidelines
with themedical recordhas been used extensively80–85and af-
fords the institution’s health care providers ready access to in-
formation noted by the Institute of Medicine as an important
tool in its recommended armamentarium for improving pa-
Currently, the library has integrated links to more than 750
guidelines within the electronic medical record. Librarians at
EBL developed a priority list of key conditions with potential
for significant impact by compiling feedback and requests
resources (National Guideline Clearinghouse, HealthGate, and
UpToDate?) to appropriate ICD-9-CM codes. The resulting
EBL-maintained data file of paired ICD-9-CM codes/guide-
lines interfaces with the StarPanel system. The ICD-9-CM
codes from Vanderbilt’s patient medical billing records drive
the linkage for displaying, within the problem list portion of
StarPanel records, the guidelines relevant to the care of indi-
a clinician caring for a patient who has received treatment at
VUMC for diabetes and hypertension will be connected with
key guidelines, such as the 2004 American Diabetes Associa-
tion standards of care87and the 2003 American College
of Physicians recommendations for blood pressure control in
Plans to further extend this functionality include establishing
linkages based on additional standard medical coding sys-
tems (for example, using Common Procedural Terminology
[CPT] codes for procedure-related guidelines) and linking
internally created sources of evidence to the patient record.
Additionally, a web portal currently in development for use
by patients remotely as well as within the clinic will provide
patients with direct access to guidelines relevant to their care.
The anticipated growth of available guidelines will make in-
formation regarding best practices seamlessly accessible for
both providers and patients, further facilitating informed
compliance and the delivery of high-quality health care.
Integrating Evidence into Pathway Development
Eskind Biomedical Library has also expanded librarians’ con-
tribution of expertise to the clinical enterprise by providing
evidence-based literature to support medical center ‘‘path-
ways’’ efforts to manage inpatient care practices. Each dis-
ease- or procedure-specific pathway defines the institution’s
daily goals for therapeutic interventions, laboratory tests, nu-
trition, nursing assessments, and consultations for treating
specific conditions.89The library has assumed a proactive
role in organizing and filtering published literature that best
addresses these pathway topics to facilitate their creation
Applying expertise gained through participation in clinical
rounds, EBL librarians utilize their subject knowledge
bases to separate pathway topics into component facets. They
then create corresponding expert search strategies for five
key online sources of primary and synthesized evidence.
Librarians also create overall analyses of the state of the liter-
ature as they review the information gained during pathway
development. These analyses detail current areas of contro-
versy, the types of studies typically encountered (e.g., few
RCT, many retrospective studies) and relevant search terms
for further exploration. The expert, topic-specific search strat-
egies as well as librarians’ overall analyses for pathways
topics reside in the EBL-created Pathway Literature Locator
(PLL) database, thereby providing automatically updated ac-
cess to evidence at the time of need. For example, the team re-
sponsible for the maintenance of the ‘‘adult splenectomy’’
pathway utilizes librarian-created search strategies to access
evidence on key facets of the topic, ranging from timing of
perioperative vaccination to specific considerations in the
myriad of indications for splenectomy. The PLL database
also accommodates specific questions from pathway team
members when more in-depth synthesis of the literature is re-
quired,providing a mechanism forcontacting the librarian re-
garding particularly focused aspects of the literature, such as
new interventions currently in the exploratory phase of clin-
Anticipating future applications of the PLL content, librarians
match ICD-9-CM codes to entries in the database. To comple-
ment outpatient evidence provided through guideline link-
ages within StarPanel, similar mapping techniques enable
StarPanel’s inpatient records to access Pathways Literature
Locator entries. Moreover, the relevance of pathway evidence
to inform creation of order sets calls for incorporation of the
PLL linkages within the hospital’s computerized physician
order entry system, WizOrder.90Through this continuing in-
tegration as members of multidisciplinary clinical teams in-
volved in pathway refinement, EBL librarians’ contributions
to defining best practices for patient care can be viewed as
proof of concept that librarian-provided evidence can affect
Successive iterations of the clinical informationist model in-
volve increasing integration of evidence-based services and
resources into clinical workflows throughout a health center’s
inpatient and outpatient practice environment. Clinical infor-
mation systems provide a rich variety of opportunities to de-
liver evidence-based information at the point of care. The
effectiveness of this type of approach, however, must still be
demonstrated formally. The EBL has completed the formative
stage and currently is in the summative phase of a three-year
evaluation (funded by the National Library of Medicine) of
GIUSE ET AL., Evolution of a Mature Clinical Informationist Model
the Clinical Informatics Consult Service’s impact on clinical
practice and decision-making at VUMC. This evaluation of
a mature clinical information approach investigates the effi-
cacy of the clinical informationist’s role as an expert informa-
tion partner in the practice of clinical medicine.
The combination of literature synthesis by trained experts
and integration with well-established clinical systems lever-
ages the strengths of both tools for facilitating clinical practice
and communication, likely leading to greater gains than
either technique in isolation. The advanced skills and for-
ward-thinking mentality of informationists make logical the
next step of integrating them into clinical software develop-
ment (informatics) teams. As team members, they can lend
their valuable expertise and perspective to further informatics
goals such as the effective use of technology to facilitate
health care processes.
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Journal of the American Medical Informatics AssociationVolume 12Number 3 May / Jun 2005