1. Introduction to Healthcare and Public Health in the US The Evolution and Reform of Healthcare in the US Lecture a This material (Comp1_Unit9a) was developed by Oregon Health & 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. The Evolution and Reform of Healthcare in the US Learning Objectives 2 Describe evidence-based medicine, clinical practice guidelines, and quality indicators in medicine (Lecture a, b, c) Describe the patient-centered medical home model (Lecture d) Discuss the key issues driving healthcare reform in the US (Lecture e) Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US The Evolution and Reform of Healthcare in the US Lecture a

3. Evidence-Based Practice (Sackett, 1996) 3 Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US The Evolution and Reform of Healthcare in the US Lecture a Evidence-Based Practice (EBP) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient.” EBP integrates “...individual clinical expertise with the best available external clinical evidence from systematic research.”

4. Evidence-Based Practice EBP is a method that helps clinicians make sound decisions about patient care EBP combines: –Clinician skills –Patient values –Evidence from research 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US The Evolution and Reform of Healthcare in the US Lecture a

5. Evidence-Based Practice: Practice Guidelines 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US The Evolution and Reform of Healthcare in the US Lecture a Practice guidelines are evidence-based recommendations In 1990, Institute of Medicine (IOM) Committee advised the Public Health Service on Clinical Practice Guidelines: –Practice guidelines are “systematically developed statements to assist practitioners and patients in making decisions about appropriate healthcare”

6. Evidence-Based Practice: Clinical Decision Support (CDS) 6 Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US The Evolution and Reform of Healthcare in the US Lecture a CDS is “...a clinical system, application or process that helps health professionals make clinical decisions” Clinical Decision Support Systems are “active knowledge systems which use two or more items of patient data to generate case-specific advice”

7. Evidence-Based Practice: Clinical Decision Support (CDS) 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US The Evolution and Reform of Healthcare in the US Lecture a Some functions of decision support systems: –Administration –Management of complexity –Cost control Decision support: Supporting clinical reasoning, promoting use of best practices

8. Hierarchy Of Evidence 8 Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US The Evolution and Reform of Healthcare in the US Lecture a Literature is ranked in a hierarchy The higher up in the ladder of evidence, the “better” the quality of the study Why have a hierarchy? –Allows grading of studies –Allows comparison of methodologies –Provides a framework that can be used during the development of systematic review protocols One method of hierarchical ordering: classify information according to effectiveness, appropriateness and feasibility

9. Hierarchy of Study Designs 9.1 Chart: The Hierarchy of Study Designs 9 Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US The Evolution and Reform of Healthcare in the US Lecture a leveldesigncomment IRandomized controlled trials Equal probability of assignment of subjects IICohort studiesDefined by exposure to factor IIICase control studiesDefined by outcome of interest IVCase seriesSystematic observation without controls VExpert opinion, physiologic studiesOnly as good as the expert

10. Some Terms Defined 10 Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US The Evolution and Reform of Healthcare in the US Lecture a Bias: Inaccuracies that produce a false pattern of differences Blinding: Attempt to eliminate bias by hiding the intervention Validity: The extent to which a variable or intervention measures what it is supposed to measure

11. Systematic Reviews 11 Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US The Evolution and Reform of Healthcare in the US Lecture a Systematic review: Search of the medical literature is conducted systematically using specific methods –Meta-analysis: A systematic review which uses quantitative methods to summarize the results Systematic reviews can be conducted –Via journal clubs –Via data mining Example: Cochrane Collaboration

12. Systematic Reviews (Continued) 9.2 Chart: Oxford EBM Hierarchy 12 Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US The Evolution and Reform of Healthcare in the US Lecture a Oxford EBM Hierarchy IaSystematic review of RCTs IbIndividual RCTs IIaSystematic review of cohort studies IIbIndividual cohort studies IIIaSystematic review of case control studies IIIbIndividual case control studies IVCase series VExpert opinion, etc.

13. PICO 13 Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US The Evolution and Reform of Healthcare in the US Lecture a Questions that are asked during Evidence- Based practice and research: P = Patient –What are the characteristics of the patient/population/problem? I = Intervention –What is the intervention, prognostic factor or exposure? C = Comparison –What is the main alternative to compare with the intervention? O = Outcomes –What is the measurement or improvement?

14. The Evolution and Reform of Healthcare in the US Summary – Lecture a 14 Definitions for EBP Practice guidelines Clinical decision support Hierarchy of evidence Systematic reviews Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US The Evolution and Reform of Healthcare in the US Lecture a

15. The Evolution and Reform of Healthcare in the US References – Lecture a References Clinical Decision Support. (n.d.). Retrieved December 6, 2011, from HIMSS website: http://www.himss.org/ASP/topics_FocusDynamic.asp?faid=313 http://www.himss.org/ASP/topics_FocusDynamic.asp?faid=313 Manchikanti, L., Singh, V., Helm II, S., Schultz, D. M., Datta, S., & Hirsch, J. (2009). Evidence-Based Medicine - An Introduction to an Evidence-Based Approach to Interventional Techniques in the Management of Chronic Spinal Pain. Pain Physician, 12(E1-E33), Retrieved from http://www.painphysicianjournal.com/2009/july/2009;12;E1-E33.pdf http://www.painphysicianjournal.com/2009/july/2009;12;E1-E33.pdf Sackett, D. L., Rosenberg, W. M., Muir Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996, January 13). Editorial - Evidence-Based medicine: what it is and what it isn't. BMJ, 312(71), Retrieved from http://www.hsl.unc.edu/Services/Tutorials/EBM/whatis.htm http://www.hsl.unc.edu/Services/Tutorials/EBM/whatis.htm Schardt, C., & Mayer, J. (2010, July). The Well-Built Clinical Question. Retrieved December 6, 2011, from University of North Carolina at Chapel Hill - Health Sciences Library, Tutorials website: http://www.hsl.unc.edu/Services/Tutorials/EBM/Question.htm http://www.hsl.unc.edu/Services/Tutorials/EBM/Question.htm Charts, Tables, Figures 9.1 Chart: The Hierarchy of Study Designs – adapted from Oxford Center for Evidence-based Medicine - Levels of Evidence. (2009, March). Retrieved December 6, 2011, from Center for Evidence Based Medicine website: http://www.cebm.net/index.aspx?o=1025–http://www.cebm.net/index.aspx?o=1025 9.2 Chart: Oxford Center for Evidence-based Medicine - Levels of Evidence. (2009, March). Retrieved December 6, 2011, from Center for Evidence Based Medicine website: http://www.cebm.net/index.aspx?o=1025 http://www.cebm.net/index.aspx?o=1025 15 Health IT Workforce Curriculum Version 3.0/Spring 2012 Introduction to Healthcare and Public Health in the US The Evolution and Reform of Healthcare in the US Lecture a