[Editors Note: at the 1998 Annual Meeting, SCOT will co-host an interdisciplinary seminar on Evidence-based medicine at the point of care with the Sections of Med/Peds, Epidemiology, and Administration and Practice Management]
Each of us regularly suffers from "information overload" because of the overwhelming number of solicited or non solicited journals and/or publications we regularly receive. On the other hand, Im sure that you share my frustration at often not having key information available at the time that a clinically significant decision must be made. Help may be at hand by combining new computer hardware and software technology (PDAs, wireless communication, client-server strategies) with the growing number of clinical parameters and protocols of care in development to either improve the quality of care or to contain costs by decreasing the local and/or regional variations in clinical decision making similar problems.
Pediatricians who practice in hospital and/or critical care settings are particularly vulnerable to the increasing complexity of medical information. Efficient and effective information retrieval would ease the information anxieties of practitioners, facilitate the selection and application of appropriate diagnostic and therapeutic interventions and thereby enhance the quality of patient care.
Evidence-based health care refers to the science associated with the collection, interpretation, and integration of valid, important and applicable patient-reported, clinician-observed, and research-derived evidence. The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments and facilitate cost-effective health care.
Evidence-based health care uses nationally developed protocols and parameters of care and/or guidelines developed by professional organizations, e.g. AAP. Guidelines may make explicit recommendations with a definite intent to influence what clinicians do. These suggestions about what should be done go beyond a simple presentation of evidence, costs, or decision models. They reflect value judgments about the relative importance of various health and economic outcomes in specific clinical situations. Consequently, researchers in evidence-based medicine believe that these strategies should be subjected to rigorous review to assess how matters of opinion and matters of science are integrated into clinical decision making.
Historically, evidence-based medicine referred to ones ability to rapidly and electronically search the medical literature. Technology now permits us to access the medical literature, a clinical algorithm, and outcomes-based data from your own institution at the point of care in the patients room or at your office. These same techniques are useful for teaching as well as clinical care. For example, we know that broadly defined CME interventions using practice-enabling or reinforcing strategies consistently improve physician performance and, in some instances, health care outcomes. Other researchers have documented that graduates of a problem-based, self-directed undergraduate curriculum are more up to date in knowledge of the management of hypertension than graduates of a traditional curriculum.
Experience-based medicine is being researched in many centers. A pioneer and leader in this field is McMaster University in Canada. McMaster has constructed a Clinical Informatics Network (CLINT). CLINTS innovation in its clinical installation within the hospital encompasses three domains: (1) a simple, flexible, clinician-computer interface in the form of graphical shell for Microsoft Windows single or networked personal computers, (2) unique, evidence-based, clinical information content, and (3) automated data collection systems that gather information about how users interact with and react to CLINT. CLINT is integrated with a graphical electronic medical record at McMaster University Hospital.
The CLINT desktop replaces the conventional Microsoft Windows "program manager" shell with a simpler interface that presents users with a personalized suite of information tools, an integrated on-line help system, and self-instructional resources. Different classes of users (e.g., medicine, nursing) are presented with different tool sets. Within each class, different levels of users (e.g., beginner, intermediate, advanced) have access to different subsets of the tools assigned to that class. Administrator's tools are used to populate different classes and levels with any Windows-compatible software.
The CLINT computer desktop controls access to all information resources and facilitates automated data collection. In addition to commercial medical applications, a CLINT workstation includes a set of practical utilities that may ease many of the more mundane informational burdens associated with clinical work. These include a special electronic mail package for keeping patient-care teams in communication; a contact manager that facilitates automated paging, telephone and facsimile contact with referring physicians and a simple problem-based notes system for internal medicine. Evidence-based information tools include a hypertext clinical practice guideline database, the electronic ACP Journal Club, and Users' Guides to the Medical Literature and Critically Appraised Topics.
At McMaster, automated user questionnaires assess function and satisfaction. They are administered at first log-on and at pre-defined intervals thereafter, including during a period defined by two administrator-specified dates (exit questionnaire). All data is registered directly to databases, and can be used to support health informatics experiments.
For more information on evidence-based medicine check out the following sites:
McMasters Clinical Informatics Network -
Share with us your experiences with evidence-based medicine via e-mail at DrJAronson@worldnet.att.net or to Mitch Feldman (SCOT Program Co-Chair) or Rick Shiffman (Evidence-based medicine program coordinator).