Usage Pattern of Medical Information through the ClinicalKey Database among Medical Professionals of the Postgraduate Institute of Medicine

The rapid proliferation of medical information in the present era has important implications for patient care, patient education, and health professionals' research. This research examines the medical information usage pattern through the ClinicalKey database of medical professionals at the Postgraduate Institute of Medicine (PGIM), Sri Lanka. The study was conducted from June 2019 to June 2021 in the postgraduate trainers and trainees of PGIM. The method used has been based on the access of medical facts available in the ClinicalKey database and a survey conducted on the usage patterns of trainers and trainees of PGIM. The results showed a growing interest in ClinicalKey among the medical professionals at PGIM. The survey showed that the majority of respondents are MD trainees. The major purpose of using resources in ClinicalKey as indicated by the users is for updating knowledge, patient care, diagnosis and treatment. Many medical professionals use the e-book: Principles and Practice of Infectious Diseases by Mandell, Douglas, and Bennett (9 th edition) and uses the journal, Surgery (Oxford). According to the keywords, ‘surgery’ is highly searched for research needs and education purposes. The study shows that medical professionals use e-resources often and spend more time on them. It is found that they use e-resources most frequently at home (48.40%). that medical professionals mostly use laptops to access e-resources of ClinicalKey, followed by tablets. Among satisfaction levels with medical information, 71.4% of the medical professionals were happy with the ClinicalKey e-resources. 14.3% of medical professionals suggested an orientation program regarding the ClinicalKey database.


Introduction
The invention of the internet has brought in an unprecedented use of e-resources for research and development in recent years compared to the diminishing use of print resources. Usage of the library by medical professionals is an essential means of enhancing their knowledge and self-directed learning skills. Information technology has affected the information-seeking behaviour of information users. Medical professionals utilise information sources such as medical databases to meet their diverse needs and to acquire up-to-date information. Williams (1992) categorised the information needs of health professionals, for example, confirming or disconfirming existing knowledge, assisting in solving a new or unfamiliar health care problem, and updating basic knowledge on a topic through review. Also, to get information from another speciality when dealing with a patient or person with multiple problems and to highlight patient care concerns to other health care team members. Further, it includes finding out about a rare or unusual patient care problem and determining whether a knowledge gap exists in the literature and whether a new research project or publication should be planned and assisting in implementing new administrative or organisational initiatives.
Medical information carries very high importance in any nation as its status determines the level of wellbeing of the people in a country (Institute of Medicine, 2003). Therefore, providing quality medical information is the duty of any government and institution dealing with medical training. This study may be more critical in postgraduate training as trainees use such information in their decision makingensuring patient safety and quality of careas well as in their professional Journal of the University Librarians Association of Sri Lanka, Vol. 25, Issue 1, January 2022, 1-30, http://doi.org/10.4038/jula.v25i1.8051 4 development. Therefore, fulfilling information needs is essential for postgraduate medical professionals to perform their professional duties efficiently and effectively. At the same time, it is also necessary that medical professionals be skilful in gathering relevant information using appropriate resources. Therefore, postgraduate training institutions in medical education should understand the importance of utilisation of electronic medical databases efficiently to fulfil the information needs.
Electronic knowledge resources have been defined as electronic (computer-based) resources comprising distilled (synthesised) or curated information that allows clinicians to select content pertaining to a specific patient to facilitate medical decision making (Aakre, 2018).
This study provides data on the effective utilisation of medical information e-resources by the postgraduate medical trainees and trainers of the PGIM, University of Colombo: with reference to the ClinicalKey database. ClinicalKey is an online search engine launched by Elsevier in April 2012, and it is one of the most significant, most comprehensive products currently available for finding clinical medical information.
Moreover, it provides an insight into clinical information that addresses essential clinical research requirements of physicians, medical librarians, and healthcare professionals. Also, it draws answers from the most extensive collection of clinical resources, covering every medical and surgical speciality (Wadasinghe, 2020). ClinicalKey offers 1362 full-text medical and surgical e-books and access to 862 full-text medical and surgical journals from the Elsevier collection and the Clinics of North America and has 11,200 practise guidelines and more than 2,600 drug monographs. It provides two types of multimedia access to 5,726,614 images and medical and surgical videos from books and journals.
A medical practitioner must be capable of diagnosing and curing patients' diseases. Medical information must be accessible, authorised, reliable, accurate and timely. There is a dire need for a solid information system for health care professionals to meet the diverse information needs to perform their professional duties effectively and efficiently.
Information about information usage patterns and information-seeking processes is essential in this regard. This study attempts to address this need of medical professionals at the Postgraduate Institute of Medicine, University of Colombo.

Statement of Problem
Library of the PGIM of Sri Lanka purchased the ClinicalKey database in 2019 to meet the information needs of present and future medical professionals. There has been no detailed study conducted so far to measure the use of e-resources of the ClinicalKey database and to assess factors that may influence the usage of these resources. Therefore, an inquiry is necessary to explore the usage of e-resources in the PGIM and the barriers that affect the effective use of these vital resources.

Scope of the Study
The scope of the study is to identify the medical information usage pattern by medical professionals in PGIM and to use its analysis to understand the impact of the medical information usage pattern of the Journal of the University Librarians Association of Sri Lanka, Vol. 25, Issue 1, January 2022, 1-30, http://doi.org/10.4038/jula.v25i1.8051 6 PGIM library. Decision-makers can use the retrieved data of the study during the planning and setting of various strategies to promote the utilisation of electronic resources in the Postgraduate Institute of Medicine and other medical institutes.

The Objective of the Study
ClinicalKey is a reliable search engine and, it is an essential database for medical and surgical information. The main objective of this study was to explore and determine the ClinicalKey medical information usage pattern of medical professionals in PGIM. The objectives of this study are given below.
• To determine the information usage patterns of medical professionals on ClinicalKey • To investigate the medical information resources used by medical professionals on ClinicalKey • To assess the level of satisfaction with ClinicalKey

Review of Literature
The utilisation of information technology to obtain medical eresources has changed the information-seeking behaviour of PGIM medical professionals across the island over the last decade. The medical professionals utilise electronic medical resources to fulfil formal academic requirements and upgrade their knowledge for continuous professional development and patient care decision-making. Also, Medical information databases and electronic resources are the crucial resources that provide medical professionals with valid and up to date scientific information. According to Callen (2008), doctors are at the Journal of the University Librarians Association of Sri Lanka, Vol. 25, Issue 1, January 2022, 1-30, http://doi.org/10.4038/jula.v25i1.8051 7 forefront of utilising modern information technologies for acquiring upto-date information. Multiple studies have been conducted to explore the effective utilisation of medical information e-resources by medical practitioners. The medical database tools help the health care professionals to make better-informed clinical decisions in a short period resulting in more accurate diagnosis and more effective treatment of the patient (Patel, 2015). Asemi & Reyahiniya (2007) also confirmed that most users are well aware of digital resources available in the library. The study highlights users are faced with problems like low-speed connectivity and shortage of hardware facilities. Moretti (2012) has surveyed access to health information on the internet and related to the public health issue. This study aims to understand the user profile and search trends for health information on the internet. This study confirmed that the internet is a significant source of health information to improve data quality and promote public health. A systematic review and metaanalysis revealed that electronic information resources were associated with higher success in answering clinical questions than alternative resources, with varying effects on speed.
When comparing different implementation options for the same electronic knowledge resource, it appears that allowing physicians to choose how they want to access the resource versus an automatic display of resource information and incorporating patient-specific data have advantages (Maggio, 2019). Studies indicate that future enhancements should include university-wide online access to reputed journals and other key resources, improved computers with fast connectivity, information literacy training programs, and continued literature search sessions are key to practicing evidence-based medicine (Perera, 2015 & Journal of the University Librarians Association of Sri Lanka, Vol. 25, Issue 1, January 2022, 1-30, http://doi.org/10.4038/jula.v25i1.8051 8 Korukire, 2018). The literature further identified some of the factors affecting the utilisation of e-resources such as lack of awareness about electronic resources available in the library, insufficient IT equipment, lack of continuous training, high cost of resources, low-speed connectivity, quality of bandwidth internet, lack of time, workloads or too tight work schedules and a distinct preference for asking an expert colleague or consulting a print source had been reported as barriers to the use of online bibliographic databases (Kwadzo, 2015;Ehioghae, 2020& Alison, 2012. Also, a few studies identified that lack of quick and easy access to information, lack of access to EBM tool and lack of skills to identify and filter the useful information as a barriers to search reliable literature for clinical decisions, safe patient care and continuous professional development. (Phua, 2007& Nwafor-orizu, 2015. The information needs of health professionals stem from various factors, including patient care, patient education, professional curiosity, and research. The type of information used by health professionals depends on several factors, including the topic or issue in question, the knowledge base of the health professional, their knowledge of information sources, and the purpose for which the information will be used.

Methodology
The trainers, trainees, examiners, academic and library staff of the PGIM have been given access to the ClinicalKey database for academic purposes through the PGIM domain email. All those registered users utilise the ClinicalKey database as remote access. The total number of 2,043 users are registered with the ClinicalKey database for the period of 2019 June to 2021 June. The main source from which the information Journal of the University Librarians Association of Sri Lanka, Vol. 25, Issue 1, January 2022, 1-30, http://doi.org/10.4038/jula.v25i1.8051 9 was gathered was the e-resources of the ClinicalKey database. In addition, all the medical professionals registered with the database were selected as the sample. Except for the library staff, 0.3% (n = 6), information was collected from all medical professionals registered with the ClinicalKey database during the survey period. Accordingly, trainers (academic staff of the PGIM) and examiners 34.3% (n = 701) and trainees 65.4% (n = 1336) were selected for the sample, respectively.
An online self-administered structured questionnaire with openended and closed questions was used to collect data regarding usability, accessibility, and the credibility of the ClinicalKey database for making clinical decisions. The questionnaire was designed and piloted with 12 medical professionals before being administered using an online Google form for participants with internet access. After conducting a comprehensive review of the literature, the questionnaire was designed. It was a well-structured questionnaire used as a tool for data collection, and collected data were analysed using SPSS statistical software.

Results and Discussion
The collected data from the ClinicalKey database and questionnaire was evaluated and interpreted, and the same is presented in the following tables and figures. Analysis of information is the decisive stride in the research process. It is the link between data and significant results leading to conclusions. With ClinicalKey, medical professionals can access the latest evidence across specialities in a variety of tools.

Performance Metrics of Registered Users
The performance metrics of month-wise registered users in the ClinicalKey database for the period 2019 to 2021 is shown in Table 1 and  According to the month-wise registered users, the lowest number of registered users are found in June 2019 (0.64%), and the highest number of registered users are found in March 2021 (6.22%).

Figure 1
Registered user count  Total 2043 100

Figure 2
Category wise data of the medical professionals

Usage Pattern of e-books
ClinicalKey provides more than 1,000 full text medical and surgical e-books.

Usage Pattern of e-journals
ClinicalKey provides more than 700 full text medical e-journals.
Ranking of the top e-journals on the research output on usage patterns for the year 2019-2021 is given in Table 3. Surgery (Oxford) is the leading journal with a maximum frequency.

Table 3
Top 25 e-journals in Clinicalkey database

Usage Pattern of Book Chapters and Journal Articles
The count of registered medical professionals who actively logged into their accounts during the reporting periods were significant.   The medical professionals used a total count of 37,329 book chapters within the study period. This analysis showed that the most used number of book chapters were in September 2020 with 4,223 (11.31%), August 2020 with 3,796 (10.17%) and February 2020 with 3,648 (9.77%) book chapters, each being published and ranked 1 st , 2 nd and 3 rd place in the period of study. According to the total number of users of journal articles (23,877), the lowest number of users was found in June 2019 (1.21%), and the highest number of users was found in June 2020 (13.12%). looked for drug and dosing information to guide treatment decision (drug), followed by 8.15% being much aware of latest clinical guidelines from the leading organisation (guideline), and 7.97% were interested in quick videos to guide the procedure for best practice (procedure consults).

Table 4
Usage pattern of clinical resources

Usage Pattern of Different Information Resources
Responses showed that the greatest number of respondents use book chapters for seeking information which is depicted in the following chart (Table 5).  Figure 4 shows the percentage of information searching view using Clinicalkey.

Content view Topic Page Views
Unique Content Titles Viewed Figure 4 reveals 82% of the content view that displays the most relevant content for each item. Furthermore, the total number of topic pages and unique content titles (it means the content is original and not duplicated anywhere else) display 9% each for the information searched by the medical professionals. Table 6 depict the preferred format for getting clinical resources information through ClinicalKey among the medical professionals. These resources are available as PDFs and can be added to presentation, emailed, and printed downloaded to read offline. Journal of the University Librarians Association of Sri Lanka, Vol. 25, Issue 1, January 2022, 1-30, http://doi.org/10.4038/jula.v25i1.8051 20

Keywords of Unique Content Titles Viewed
Highly productive keyword areas output for the study period of 2019 to 2021 found a total of 25 specialities.

Purpose of Using e-resources of ClinicalKey
Medical information helps medical professionals with decisions and actions. It enhances patient care by making it more efficient while the patient records and medical knowledge are captured, processed, communicated, and applied (Wyatt & Sullivan, 2005).
The study sought to determine the purposes of using electronic resources by trainers, trainees and academics attached to the PGIM. To obtain the answers, the respondents were asked to indicate their purposes of using ClinicalKey in their respective locations, as outlined in the figure below.

Figure 5
Purpose of using e-resources of ClinicalKey Figure 5 above presents the information on the purpose for using resources in ClinicalKey by users. For up-to-date knowledge (96.4%) was ranked highest as the main purpose for using resources in

Frequency of Using e-resources
Medical professionals were requested to mark their frequency of the use of e-resource under one of the headingsvery-often, often, sometimes, and rarely ( Figure 6) to determine the frequency of use of eresources of ClinicalKey. Regarding the frequency of using e-resources, the respondents have reacted differently. Figure 6 shows Lanka, Vol. 25, Issue 1, January 2022, 1-30, http://doi.org/10.4038/jula.v25i1.8051 23

Figure 6
Frequency of the use of e-resources of ClinicalKey

Location of Accessing of ClinicalKey e-resources
Medical professionals were requested to mention their most convenient location or using ClinicalKey e-resources (Figure 7).

Figure 7
Place of accessing ClinicalKey The place of accessing e-resources of ClinicalKey by medical professionals is mostly from home (48.40%, n=985). It was followed by Journal of the University Librarians Association of Sri Lanka, Vol. 25, Issue 1, January 2022, 1-30, http://doi.org/10.4038/jula.v25i1.8051 24 the number of accesses at the workplace with 29.20% (n=595). While 11.55% (n=235) use and access e-resources while travelling and 10.9%(n=222) use the e-resources at the library of the PGIM.

Usage of Devices to Access
The chart below depicts the preference for comfortable handling of the devices by medical professionals.

Figure 8
Usage of devices to access the e-resources of ClinicalKey The most used devices to access ClinicalKey e-resources are laptop computers followed by tab computers. Use of smart phone is 20.2% and desktop computer 8.1%.  Lanka, Vol. 25, Issue 1, January 2022, 1-30, http://doi.org/10.4038/jula.v25i1.8051 25 medical professionals with e-resources for retrieving the required information, most of the medical professionals were satisfied with their effectiveness in answering specific clinical questions (74.5%), followed by 73.3% with the ease-of-use whereas 71.4 % for overall satisfaction with ClinicalKey database. Above figure 9 shows that 63.2% are satisfied with the quality of the answer that was found, and 59.8% are happy with the quality of their solution. Followed by 56.6% being pleased with the usefulness of instructions and 51.7% being satisfied with userfriendliness.

Figure 9
Level of satisfaction with ClinicalKey resources

Satisfaction level with Clinicalkey
Journal of the University Librarians Association of Sri Lanka, Vol. 25, Issue 1, January 2022, 1-30, http://doi.org/10.4038/jula.v25i1.8051 26 satisfaction with the ClinicalKey database, the majority of respondents are delighted with the medical information of the ClinicalKey.

Conclusion
Medical information is essential for medical professionals to diagnose and cure patients' diseases. There was a need for a solid information system for health care professionals to meet the diverse information needs in performing their professional duties effectively and efficiently. The main objective of this study is to improve the provision of high-quality medical information to PGIM medical professionals.  Lanka, Vol. 25, Issue 1, January 2022, 1-30, http://doi.org/10.4038/jula.v25i1.8051 27 journals. ClinicalKey electronic resources impose a significant impact on medical professionals' use of medical information.
The analysis of the study shows that ClinicalKey electronic resources plays a vital part in medical information provision and are widely used by medical professionals of PGIM. It has an impact on the way of searching and disseminating information. It reveals that most medical professionals are aware of ClinicalKey e-resources and use this e-resource to search for medical information online. However, this finding showed that most of the respondents were using electronic databases purposely for research activities and thesis writing. Hence there is a dire need for effective user education, orientation programme, workshops, seminars etc. among the medical professionals of the PGIM so that they can get the maximum benefit from the e-resources of

ClinicalKey.
The study concluded that ClinicalKey e-resources provide the opportunity to access the current and up-to-date data/information. These valuable information resources have been utilised by most of the medical professionals of the PGIM for better informed and updated medical knowledge.