1. The Culture of Healthcare
Evidence-Based Practice
Welcome to The Culture of Healthcare: Evidence-Based Practice. This is Lecture a.
The component, The Culture of Healthcare, addresses job expectations in healthcare settings. It discusses how care is organized within a practice setting, privacy laws, and professional and ethical issues encountered in the workplace.
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 IU24OC

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)
By the end of this unit, Evidence-Based Practice students will be able to:
Define the key tenets of evidence-based medicine (EBM) and its role in the culture of health care
Construct answerable clinical questions and critically appraise evidence answering them
Apply EBM for intervention studies, including the phrasing of answerable questions, finding evidence to answer them, and applying them to given clinical situations
Understand EBM applied to the other key clinical questions of diagnosis, harm, and prognosis
Discuss the benefits and limitations to summarizing evidence
Describe how to implement EBM in clinical settings through clinical practice guidelines and decision analysis
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
This lecture is an introduction to the unit topic – Evidence-Based Medicine.
Evidence-based medicine or EBM [E-B-M] can be defined as a set of tools and a disciplined approach to informing clinical decision making. We apply the best scientific evidence available to various clinical questions. We learn to seek out the best evidence and how to use it appropriately, though we cannot forget the caveat that comes from a quote of Carl Sagan [say-gehn], obviously not applying to medicine but being pertinent here, that absence of evidence is not evidence of absence. Not do we have to know what evidence is there, but what evidence is missing and how that might influence our decision making. Therefore, EBM allows clinical experience or the art of medicine to be integrated with the best science, making the medical literature more clinically applicable and relevant.
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
So what’s the big deal about evidence-based medicine? Why are we not evidence-based in everything that we do?
There are some interesting writings from the popular press that talk about how humans arrive at decisions and how they apply evidence. Not just in medicine, at least in the case of one, but in everything we do. Kida has a book that describes six ways that humans come to false beliefs. One is that we tend to prefer stories over statistics. The second is that we often seek to confirm and not to question our ideas. Another issue is that humans rarely appreciate the role of chance and coincidence in shaping events, although those exposed to EBM are hopefully a little better at that. Sometimes we misperceive what is going on in the world around us. Sometimes we oversimplify our thinking and human memories are often inaccurate. We do not always remember things exactly as they occurred, especially over time.
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)
There is a growing advocacy for medicine being more evidence-based. One of the six attributes of the high-quality twenty-first century health care system in the Institute of Medicine or IOM [eye-oh-em] Crossing the Quality Chasm [kazm] report was effectiveness, referring to the use of EBM principles. There have been other reports in this series, one in particular that talked about the “learning health care system” that learns from what we do. Naturally the main way to learn from what we do is to collect data and analyze it, something that can be done without computer-based information systems. And then this has given vision to the idea of having a better sense of what works in health care. Now EBM has many methodological details and challenges. We will cover some of them in this unit. There are also more detailed descriptions of these challenges in a supplement to the journal, Medical Care, from 2007.
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
One of the new foci of the EBM community is comparative effectiveness research, or CER [C-E-R]. Like health information technology, this achieved new, highly visible prominence through its funding in the American Recovery and Reinvestment Act, or ARRA [err-uh]. Completely aside from all the health information technology (IT [eye-tee]) funding, the stimulus bill also allocated one-point-one billion dollars for comparative effectiveness research. There was also a stipulation that two reports be prepared to inform the operational plan or comparative effectiveness research. These reports were published in June, 2009 – one by the Federal Coordinating Council for comparative effective research and the other from the Institute of Medicine prioritizing research topics.
The Federal Coordinating Council report defined CER, which will be covered in the next slide. The report called for emphasis not only on the research that needed to be done, but also on other aspects around it such as human and scientific capital. This includes developing individuals with the expertise to do the research; scientific methodology to carry it out; data infrastructure to support it, including registries, data warehouses, and other electronic data sources; and then a mechanism to disseminate this research so it gets into the hands of decision makers, patients, clinicians, policy makers. The IOM [eye-oh-em] report then prioritized one hundred top research priorities that not only address the common diseases that require a lot of resources to treat, but also address issues around health care delivery and health disparities.
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
The Federal Coordinating Council developed a definition of comparative effectiveness research, of which some key points are summarized here. CER [C-E-R] is defined as research comparing different interventions and strategies to prevent, diagnose, treat, and monitor health conditions. The key aspect of comparative effective research is that it compares one approach versus another or a group of approaches, rather than taking one study that compared something with a placebo and another study that compared something else with a placebo and trying to decide which is better.
Beyond the research, CER [C-E-R] must assess a comprehensive array of health-related outcomes for diverse patient populations. This refers not only to things like gender or ethnic diversity, but also to patients who have chronic conditions or multiple conditions that interact with each other. And finally, one point relevant especially to informatics [in-fer-mat-iks], is that CER [C-E-R] necessitates the development, expansion, and use of a variety of data sources and methods. In addition to clinical trials, this refers to mining data bases of electronic health records using appropriate caveats, and other sorts of things.
Furthering the agenda of CER [C-E-R] is a mandate in the federal health reform legislation (the Affordable Care Act, or ACA [ay-see-ay]) for the funding of the Patient-Centered Outcomes Research Institute or PCORI [pee-core-ee] ( an Independent body with multiple stakeholder representation, to advance and carry out research in CER [C-E-R].
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,
Independent body with multiple stakeholder representation to advance and carry out research in CER (Washington, 2011)
The Federal Coordinating Council developed a definition of comparative effectiveness research, of which some key points are summarized here. CER [C-E-R] is defined as research comparing different interventions and strategies to prevent, diagnose, treat, and monitor health conditions. The key aspect of comparative effective research is that it compares one approach versus another or a group of approaches, rather than taking one study that compared something with a placebo and another study that compared something else with a placebo and trying to decide which is better.
Beyond the research, CER [C-E-R] must assess a comprehensive array of health-related outcomes for diverse patient populations. This refers not only to things like gender or ethnic diversity, but also to patients who have chronic conditions or multiple conditions that interact with each other. And finally, one point relevant especially to informatics [in-fer-mat-iks], is that CER [C-E-R] necessitates the development, expansion, and use of a variety of data sources and methods. In addition to clinical trials, this refers to mining data bases of electronic health records using appropriate caveats, and other sorts of things.
Furthering the agenda of CER [C-E-R] is a mandate in the federal health reform legislation (the Affordable Care Act, or ACA [ay-see-ay]) for the funding of the Patient-Centered Outcomes Research Institute or PCORI [pee-core-ee] ( an Independent body with multiple stakeholder representation, to advance and carry out research in CER [C-E-R].
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Evidence-Based Practice Lecture a

9. The Culture of Healthcare Evidence-Based Practice Lecture a
Unit Topics
Definitions and Application of EBM
Intervention
Diagnosis
Harm and Prognosis
Summarizing Evidence
Putting Evidence into Practice
In this unit, we will begin in the next lecture with definitions and applications of EBM. We will then look at the major questions – types of clinical questions that EBM tries to answer--questions about intervention, about diagnosis, about harm and prognosis. We will look at techniques for summarizing evidence, such as systematic reviews and medical analyses that bring multiple studies together to give us a more comprehensive picture. We will then look at some approaches to putting evidence into practice, in particular, clinical guidelines and decision analysis.
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
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
This concludes Lecture (a) of Evidence-Based Practice.
In summary, EBM is an approach to informing clinical decision-making that applies the best evidence available. It allows clinical experience (art) to be integrated with best clinical science and makes medical literature more clinically applicable and relevant.
Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Evidence-Based Practice Lecture a

11. Evidence-Based Practice References – Lecture a
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
Anonymous. (2009b). Initial National Priorities for Comparative Effectiveness Research. Washington, DC: Institute of Medicine. Retrieved from
Anonymous. (2009c). Initial National Priorities for Comparative Effectiveness Research. Washington, DC: National Academies Press. Retrieved from
Cohen, A., Stavri, P., & Hersh, W. (2004). A categorization and analysis of the criticisms of evidence-based medicine. International Journal of Medical Informatics, 73,
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,
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
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Health IT Workforce Curriculum Version 3.0/Spring 2012
The Culture of Healthcare Evidence-Based Practice Lecture a