Teaching Evidence Assimilation for Collaborative Health Care Building Capacity for Scientifically Informed Healthcare Peter Wyer MD Co-Chair, Section on Evidence Based Health Care New York Academy of Medicine Department of Medicine, Columbia University Medical Center

ACKNOWLEDGEMENTS SEBHC TEACH Team Advisors NYAM Staff Arlene Smaldone Peter Wyer Co-Chairs Barney Eskin Secretary Michael Cantor Treasurer Sharron Close Dawn Dowding Louise Falzon Pat Gallagher Jaime Gray Judy Honig TJ Jirasevijinda Vepuka Kauari Julia Lavenberg Nikhil Mull Allison Piazza Patricia Quinlan Karen Schoelles Suzana Alves Silva Alexandr Tichter Jonathan Treadwell Ian Graham Eddy Lang Sharon Straus Henry Ting Marita Titler Craig Umscheid Donna Fingerhut Margarita Guevara Reggie Richards-Peelle Anthony Shih

DISCLOSURES No Faculty Disclosures Declared TEACHING EVIDENCE ASSIMILATION FOR COLLABORATIVE HEALTHCARE DISCLOSURES No Faculty Disclosures Declared Generous Donation of Electronic Resources: Annals of Internal Medicine (ACP Journal Club) BMJ Group (Clinical Evidence, Best Practice, EB Journals) Wiley (Cochrane Library) EBSCO (Dynamed, CINAHL) McGraw-Hill-JAMA (JAMAEvidence) Wolters-Kluwer (Joanna Briggs) ACKNOWLEDGEMENT ECRI Institute

TEACH Evidence Assimilation Collaborative Health Care

Defragmentation of EBCP Knowledge translation/evidence-based practice Development of clinical policies and guidelines Foundations of evidence-based healthcare

Common Skills Across Dimensions Problem delineation Formulating information needs Finding the most relevant evidence Appraising evidence quality and importance Integration with practice-based evidence Assimilation of resulting knowledge into clinical and systems level actions

Level 1 Narrative, interpersonal and epidemiological skills Constructed priorities and preferences Road Map for evidence literacy Defining information needs Finding relevant and applicable research Evaluating the quality of evidence Reconsidering applicability to healthcare, policies and practice

Level 2 Practice based health technology assessment Clinical policies and recommendations Specific health care settings Guideline appraisal and adaptation The GRADE system

Level 3 Team based problem definition Gathering ‘internal’ + ‘external’ evidence Use of health services/implementation research Analysis of barriers and facilitators Educational interventions, decision support Monitoring measurable and sustainable impact Maintaining currency and sustainability

A Quality Improvement Orientation Start with problem, not the evidence Use practice based data Integrate use of research with operations and work flow Adhere to the focus on patient-important outcomes = the ‘central dogma’ of EBM

The Road Map Patient Centered Information Queries “Given my personal characteristics, conditions and preferences, what should I expect will happen to me?”  (Frequency) ‘How confident should I be in the criteria you/we are using to answer the previous question?’  (Performance) “What are my options and what are the potential benefits and harms of those options?”  (Utility)

The Road Map Hierarchy of Information

NOT: “Not EBM” EBM no longer defined in the literature, hence cannot say “this is ‘not EBM’”!

Relationship Centered Care 1993-94: Pew Commission/Fetzer Inst Tasked to integrate psychosocial and biomedical issues in health care Proposed epistemologically defined construct Polanyi: tacit dimension Merleau-Ponty: predecessor of complexity theory Explicitly identified tendencies Schon: Reflective action Engel: Biopsychosocial model Subsequent developments-relationship to complexity theory, complex adaptive systems, Wyer, Silva, Post ,Quinlan. J Eval Clin Pract 2014

The social processes of healthcare Research literacy Silva SA, Charon R, Wyer PC. JECP. 2011;17:585-593

Summary and Clarification “EBP”≠ “EBM” Emphasis on applicability and adaptation Reject fixed hierarchy of research designs RCT evidence relevant but may be indirect A QI approach to “EBP”