1. The Culture of Healthcare Evidence-Based Practice Lecture a This material (Comp2_Unit5a)was developed by Oregon Health and Science University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015.

2. Evidence-Based Practice Learning Objectives Define the key tenets of evidence-based medicine (EBM) and its role in the culture of health care (Lectures a, b) Construct answerable clinical questions and critically appraise evidence answering them (Lecture b) Apply EBM for intervention studies, including the phrasing of answerable questions, finding evidence to answer them, and applying them to given clinical situations (Lecture c) Understand EBM applied to the other key clinical questions of diagnosis, harm, and prognosis (Lectures d, e) Discuss the benefits and limitations to summarizing evidence (Lecture f) Describe how to implement EBM in clinical settings through clinical practice guidelines and decision analysis (Lecture g) 2 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Evidence-Based Practice Lecture a

3. What is Evidence-Based Medicine (EBM)? A set of tools and disciplined approach to informing clinical decision-making –Applies the best evidence available –Though cannot forget the caveat: “Absence of evidence is not evidence of absence” (Carl Sagan) Allows clinical experience (art) to be integrated with best clinical science Makes medical literature more clinically applicable and relevant 3 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Evidence-Based Practice Lecture a

4. Why Are We Not Evidence-Based? Thomas Kida (Kida, 2006) lists six ways we arrive at false beliefs –We prefer stories to statistics –We seek to confirm, not to question, our ideas –We rarely appreciate the role of chance and coincidence in shaping events –We sometimes misperceive the world around us –We tend to oversimplify our thinking –Our memories are often inaccurate 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Evidence-Based Practice Lecture a

5. Growing Advocacy For Medicine Being More Evidence-Based “Effectiveness” was one of 6 attributes advocated in IOM Quality Chasm report (Anonymous, 2001) A recent report in this series advocates this in more detail and advocates use of informatics for a “learning health care system” (Eden, Wheatley, McNeil & Sox, 2008) Descriptions of methodological details and challenges for EBM, in supplement to Medical Care (2007, 47:10 Supp 2) 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Evidence-Based Practice Lecture a

6. “Cultural” Pushback on EBM Not everyone agrees with the experimentally oriented approach of EBM (Luce, et al., 2009) There are some valid criticisms of EBM (Cohen, Stavri, & Hersh, 2004) –Challenges physician-patient autonomy –Focuses on large-scale randomized controlled trials that homogenize individual differences –Concerns about manipulations of clinical trials data and reports 6 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Evidence-Based Practice Lecture a

7. The New EBM Mantra: Comparative Effectiveness Research Achieved new prominence when American Recovery and Reinvestment Act (ARRA) allocated $1.1 billion for comparative effectiveness research (CER) –Required preparation of two reports to inform operational plan Federal Coordinating Council for CER (Anonymous, 2009a) Defined CER (next slide) Called for development not only of research but also human and scientific capital, data infrastructure, and dissemination IOM report for prioritizing research (Anonymous, 2009b; Anonymous, 2009c) Identified top 100 research priorities 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Evidence-Based Practice Lecture a

8. Comparative Effectiveness Research (continued) Definition of CER from Federal Coordinating Council report –“research comparing different interventions and strategies to prevent, diagnose, treat and monitor health conditions” –“must assess a comprehensive array of health-related outcomes for diverse patient populations” –“necessitates the development, expansion, and use of a variety of data sources and methods” (informatics!) – Healthcare reform legislation (Affordable Care Act, ACA) allocated funding for Patient-Centered Outcomes Research Institute (PCORI, www.pcori.org)www.pcori.org –Independent body with multiple stakeholder representation to advance and carry out research in CER (Washington, 2011) Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Evidence-Based Practice Lecture a 8

9. Unit Topics 1.Definitions and Application of EBM 2.Intervention 3.Diagnosis 4.Harm and Prognosis 5.Summarizing Evidence 6.Putting Evidence into Practice 9 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Evidence-Based Practice Lecture a

10. Evidence-Based Practice Summary – Lecture a 10 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Evidence-Based Practice Lecture a EBM is an approach to informing clinical decision-making that applies the best evidence available Allows clinical experience (art) to be integrated with best clinical science Makes medical literature more clinically applicable and relevant

11. Evidence-Based Practice References – Lecture a 11 Health IT Workforce Curriculum Version 3.0/Spring 2012 The Culture of Healthcare Evidence-Based Practice Lecture a References Anonymous. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press. Anonymous. (2009a). Federal Coordinating Council for Comparative Effectiveness Research - Report to the President and the Congress. Washington, DC: Department of Health and Human Services. Retrieved from http://www.hhs.gov/recovery/programs/cer/cerannualrpt.pdf http://www.hhs.gov/recovery/programs/cer/cerannualrpt.pdf Anonymous. (2009b). Initial National Priorities for Comparative Effectiveness Research. Washington, DC: Institute of Medicine. Retrieved from http://www.iom.edu/Reports/2009/ComparativeEffectivenessResearchPriorities.aspx Anonymous. (2009c). Initial National Priorities for Comparative Effectiveness Research. Washington, DC: National Academies Press. Retrieved from http://www.nap.edu/catalog.php?record_id=12648http://www.nap.edu/catalog.php?record_id=12648 Cohen, A., Stavri, P., & Hersh, W. (2004). A categorization and analysis of the criticisms of evidence-based medicine. International Journal of Medical Informatics, 73, 35-43. Descriptions of methodological details and challenges for EBM. (2007). In Medical Care – Supplement 2 (47:10). Eden, J., Wheatley, B., McNeil, B., & Sox, H. (Eds.). (2008). Knowing What Works in Health Care: A Roadmap for the Nation. Washington, DC: National Academies Press. Kida, T. (2006). Don’t Believe Everything You Think: The 6 Basic Mistakes We Make in Thinking. Amherst, NY: Prometheus Books. Luce, B., Kramer, J., Goodman, S., Connor, J., Tunis, S., Whicher, D., & Schwartz, J. (2009). Rethinking randomized clinical trials for comparative effectiveness research: the need for transformational change. Annals of Internal Medicine, 151, 206-209. Washington, A., & Lipstein, S. (2011). The Patient-Centered Outcomes Research Institute — promoting better information, decisions, and health. New England Journal of Medicine, 365, e31. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMp1109407 http://www.nejm.org/doi/full/10.1056/NEJMp1109407