1. Knowledge management and information and communication technology International Clinical Epidemiology Network, XIXth annual meeting Kunming, China Fiona Godlee Head of BMJ Knowledge Editor, Clinical Evidence www.clinicalevidence.com

2. “Seeing both sides of the moon Making the most of what we know and what we don’t know in health care”

3. “Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?” T.S. Eliot, poet

4. “Knowledge may gain a woman much applause, but it will not add a single lover to her list.” Jane Austen, 18th century writer

5. Foreground knowledge –needed for a specific clinical task –eg. Give IV thrombolysis for AMI, but beware of hypotension Background knowledge –needed to understand the foreground knowledge –eg. What is hypotension and how do I measure it? –Scott Richardson

6. “To me, “knowledge” is about access and understanding. Action is then a choice (hopefully an informed one) for the individual.” Chris Silagy, Australia 1999

7. Access Need access to –good primary studies, systematic reviews and synopses Barriers to access –cost –copyright –paper is expensive and quickly out of date –online is cheaper but not widely available

8. Improving access Hinari Open Access initiatives PubMed Central BioMed Central www.biomedcentral.com Public Library of Science Soros Foundation Open archiving

9. Understanding Making information “actionable” Turning “know about” into “know how”

10. Data Information Know About Know How Action

11. Getting evidence into practice - we know that... Information alone is not enough Simple messages are best There’s no magic bullet - multifaceted interventions work best (but are more expensive!) Need to begin with “diagnostic analysis” to identify barriers and facilitators for change Need to take account of local circumstances –NHS Centre for Reviews and Dissemination. Getting Evidence into Practice. Effective Health Care 1999; 5: 1-16.

12. Getting evidence into practice - we suspect that these will help Combining “foreground” and “background” knowledge Making the information “actionable” –At point of care –Integrated into patient record Giving the same information to patients Giving information in the form of learning

15. interactive Therapeutic Option Evidence for different patient groups From this….. To this….. Individual Patient Evidence for different therapeutic options

16. interactive - an overview Electronic Medical Record interactive Patient specific knowledge where and when it is needed

17. interactive in practice Physician or patient accesses CE-i from within electronic patient record or online Appropriate clinical question is selected –‘What are the next treatment options for my patient with heart failure?’ CE-i question

18. interactive in practice AREZZO loads the questions CE-i collects information about the individual patient from EPR CE-i then asks the user for any extra information clinical questions for decision support

19. interactive in practice CE-i provides: the two ‘next best’ treatments a summary of other treatment options, which the user can browse customised CE output

21. BMJ Online Learning Appraisal made easy Learning needs assessment Automatic record keeping Learning resources matched to needs Just in time modules Help with the forms

22. Interactive case histories Problem solving format Entertaining and educational

23. Assess your learning needs Seven different types of assessment tool Some involve self assessment, others require input from colleagues and patients Optional for those who want to go straight to the learning

24. Evidence database Data from appropriate SRs and RCTs Evidence “engine” Compendium of evidence DOCTOR BMJ Knowledge products BT (Ingenix, other US, UK) Preference engine BT clinician BT patient Action Data CE Book, web, CD ROM BMJ Learning Patient online learning CE-i BT-i for patients CE Pocket Clinician (concise) Best Treatments Interactive Doctor-patient Patient Doctor Patient information leaflets) Targeted learning for outlier MDs Personalized online learning Just in time learning

25. Creating useful knowledge products - Rule # 1 Be “question driven” not “research driven” Even though being question driven is harder –research is finite, questions are infinite –how decide which questions? WHOSE questions? Because otherwise –you’ll find what the research wants to tell you not what you want to know –you’ll be looking where the light is not where the problem is –you won’t identify the knowledge gaps

26. Creating useful knowledge products - Rule # 2 What we don’t know is as important as what we do know We can show the dark as well as the light side of the moon - Jerry Osheroff

27. What’s on the dark side of the moon? Questions not studied at all Studied but in small or poor quality trials Wrong outcomes –Didn’t look at outcomes that matter to patients (eg. acceptality or quality of life) –Didn’t look at adverse events Too selective –Didn’t include elderly people or those with comorbidity Not studied in relevant settings –Done in tertiary referral centre, not community hospitals

28. Why show the dark side? A powerful force for changing the research agenda So clinicians can distinguish between individual uncertainties and shared uncertainties So patients can understand the limits of knowledge in health care To create valid space for patient preferences and “best practice”

29. What is INCLEN’s role? High quality primary research, asking the right questions in relevant settings and populations High quality systematic reviews and overviews Evidence based and prioritised guidelines (KPP) Evaluating the effectiveness of EB materials in practice

30. Conclusions - I Knowledge is about access and understanding The aim is to allow informed choices There is a range of ways to get evidence into practice: some tested, most not Creating knowledge products that interact with patient information seems a good idea So does giving clinicians and patients the same information

31. Conclusions II Knowledge should be question driven It should be firmly based on sound evidence Identifying the gaps in our knowledge is helpful and may influence the research agenda We don’t really know if any of this improves health care - INCLEN might like to investigate this!

32. Thank you Fiona Godlee fgodlee@bmjgroup.com