If you’re looking for evidence-based health information in Canada, a lot depends on who – and where – you are. A physician in a teaching hospital? No problem. But family doctors in rural areas, nurses or physiotherapists have a much harder time accessing up to date materials. And the general public is more likely to find themselves turning to Dr. Google than trustworthy sources.
In Norway, these differences disappear. Rural physicians and motivated patients can read the same high-level information a doctor in the largest hospital enjoys. That’s thanks to the Norwegian Electronic Health Library, an eight-year-old project that allows anyone in the country to log in to over 3,000 titles, including the most important medical journals, Cochrane Reviews and clinical resources like UpToDate.
A similar initiative for a pan-Canadian health library recently failed. But Norway’s egalitarian approach offers a glimpse into what it could have been.
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The wealth, the will, and the way
Thanks to its oil reserves, Norway is one of the richest countries in the world. Despite that, finding funding for the library was a challenge. The money, which comes from the government, was diverted from hospital budgets, and the institutions were resistant to give up the income as well as the autonomy. (Some, like university hospitals, still supplement the electronic library with their own additional subscriptions for researchers.) “Everyone thinks it’s a good idea, but it’s hard to get someone to give up some of their own money,” says Magne Nylenna, the project’s editor-in-chief. He believes the library saves money overall. In a 2010 article in The Lancet, he writes that it cost $9 million Cdn, or $44 per health-care professional. Institutional licences would have cost three to four times that.
Canada could also benefit from the bargaining power that comes with buying in bulk. And a national licence would prevent duplication, where journals charge multiple times for the same physicians, who have access through several places, like a hospital and a university.
Recently, the Canadian Health Libraries Association tried to create the Canadian Virtual Health Library. The library would have offered all health-care workers access to a network of libraries across the country through a bilingual site. The project received an $800,000 grant from the Canadian Institutes of Health Research over three years, starting in 2010. But without federal support, it didn’t take root, and has since shut down. “The logistics of trying to get to a pan-Canadian licence on anything – just to get all the people at the table is crazy,” says Lee-Anne Ufholz, president of the Canadian Health Libraries Association. “Norway’s project is beautiful and I’m totally jealous, but they just didn’t have the complexity that we were looking at.”
‘The democratization of knowledge’
The Norwegian electronic library initiative is based on the principle that everyone deserves equal care, and that requires equal access to health information. “We call it the democratization of knowledge,” says Nylenna. “If [rural and urban areas] aim at the same sort of quality of care, we should have the same access to the same quality of information and knowledge.”
The electronic library is part of The Norwegian Knowledge Centre for the Health Services, which helps promote evidence-based health information throughout the country. The e-library lets users view information by medical specialty and type, or by using a bilingual search function that includes Norwegian and English. About 200,000 to 250,000 unique users access it per month, in a country of just 5 million.
Canadian physicians across the country have access to some resources through the Canadian Medical Association. Its searchable online databases offers access to resources including the Canadian Medical Association Journal, clinical practice guidelines and DynaMed, as well as dozens of medical journals and textbooks. “Twenty years ago, a family doctor would keep a copy of Harrison’s textbook of medicine and a couple of [other] textbooks on the shelf, and now that just doesn’t work,” says Sam Shortt, director for quality initiatives at the Canadian Medical Association. Its goal is to “give every doc coast to coast access to the key materials.”
However, some things are still missing. Cochrane Reviews used to be available, but the CMA found they weren’t well read and stopped offering them. UpToDate, which many physicians believe is the best resource on the web, and many high-end journals, including The New England Journal of Medicine, aren’t offered because of their higher costs. “There are some journal gaps,” says Shortt.
Cochrane summaries and abstracts are also available to all health-care providers and the public. But there isn’t a national licence for the full text. Cochrane Canada director Jeremy Grimshaw estimates a national licence would cost about $550,000 to $650,000, and that Canada is currently spending about $50,000 more than that on individual licences. “Patients expect that our family doctors have the most up to date information – the trust in family practitioners is very much based on that idea. And we’re not making it easy for family doctors to have access to that knowledge,” says Grimshaw.
The Canadian Nurses Association has a similar portal as the CMA’s, called NurseONE. It offers members access to resources including Cochrane reviews, 3,700 journals, including the BMJ and CMAJ, DynaMed and over 1,000 books. It averages 11,700 unique visitors a month.
Nurses, along with psychiatrists and physiotherapists, are one of the groups who benefited the most from the Norweigan electronic library. They’re also one group the Canadian Virtual Health Library was trying to reach. “There is a need for access for not just physicians …. but for nurses, or even social workers, rehabilitation sciences people, who are underserved in how they access information,” says Ufholz.
Quality over quantity
Norway’s electronic library focuses on quality, using only articles from trustworthy journals. One way they do that is by subscribing to McMaster PLUS, a service from Hamilton’s McMaster University that acts as a filter for high-quality sources. Staff review more than 120 journals to see if articles are scientifically sound, relevant and interesting. That helps make keeping up more manageable for doctors, who report being overwhelmed by information. “It’s this incredible reduction in the noise-to-signal ratio,” says John Lavis, director of the McMaster Health Forum. Norway’s version has been customized for them, but the service is free to anyone globally.
It’s even harder for the public to distinguish between high- and low-quality information. Information for patients needs to be written in plain English, like the Cochrane review’s accessible summaries. And screening out low-quality health information is crucial, as the media – and online sources – play up counterintuitive and sensational findings. In Norway, the electronic library helps solve that problem too, with increasing numbers of users looking at patient information sheets; many of the users are coming straight from Google.
“I often talk about diabetes, clinically, as starving in a banquet hall. Diabetes information is the same thing,” says Jan Hux, chief scientific advisor at the Canadian Diabetes Association. Despite being surrounded by millions of articles online, she says, “people are starving for information.”