The interplay between knowledge management, health informatics and evidence based medicine
The practise of medicine is a knowledge intensive endeavour. The aim is the application of up-to-date, relevant, valid and practise changing information in the management of patients. Hence, the challenge lies in "generating structured answerable questions" and the ability to "find the information needed" to answer the questions within "each patient encounter".
Evidence Based Medicine
Over the past 10 years, a lot of work has been done by Sackett and his colleagues to try and address this. This practise has been named “Evidence-based Medicine” or EBM for short. It has five steps, which needs to be applied each time in the search of information pertinent to the individual patient. They are listed below:
- Recognise the need for information and generate structured answerable questions.
- Search for the evidence to answer the question.
- Critically appraise the evidence found for relevance and validity.
- Tailor the evidence to the needs and preferences of the individual patient.
- Audit and review one’s own practice
Based on the above, it can be seen that information found using the 5 steps of EBM can be useful information, as long as the work required to find it is not too laborious.
This can be defined by the equation
U=V x R / W as proposed by Slawson and Shaughnessy;
U=Usefulness of the information,
V=Validity of the information,
R=Relevance of the information to the particular patient and
W=Work needed to find the information.(14)
The validity of the information relates to the scientific rigor of the research that produced it. Even large randomised clinical control trials may not produce valid data if the trial had been poorly designed, influenced by bias or does not answer the question that it originally set out to answer.
The relevance of the information refers to the question of whether the application of the information affects the outcomes that matter most to the patient. This usually means a symptom free and functional life, not just the prolongation of life.
The work needed to find the information is also very important as the harder it is to find the information, the less likely it is going to be used.
In the ideal world, the evidence should be presented to the clinician in a seamless Electronic Health Care Record environment at the point of care, without interrupting the clinical workflow.
Sources of Information and knowledge
The primary source of information has traditionally been the original biomedical journals themselves. They are accessed via Medline, which is a database of biomedical journals since 1966. To date, there are over twelve million records of which only 75 % of them have abstracts.
Due to the high noise to signal ratio, an experienced used can only expect to find 45 % of the available evidence. The figure is even more abysmal for the inexperienced user at around 15 %. Of note is the amount of work required to search for the evidence for one question; 43 minutes for the average librarian in one study.(10)
More useful are the secondary sources of information, which include the Cochrane Database of Systematic reviews, the Evidence-based Medicine Journal and the American College of Physician Journal Club. The papers presented in these sources are chosen based on their validity; and would only represent around 6 % of the total available evidence.
In the past few years, tertiary sources of information have been developed in order to encourage and enable EBM in the real world. These sources of information not only sieve the evidence base for validity, but also ensure their relevance by subjecting them to internal peer review by practising clinical experts in the particular field.
The "Work" factor has also been addressed by making the evidence available at the point-of-care via Personal Digital Assistance, through access via the World Wide Web and mobile wireless-network terminals.
UpToDate, Essential Evidence Plus and POEMS
The two leaders in this field are UpToDate and InfoRetriever (now known as Essential Evidence Plus). Access at the point of care is very important as this would increase the likelihood of the search for and integration of EBM in clinical practice. In order to encourage its use, the access of the on-line version is automatically recorded for the award of Continuing Medical Education credits.
There has also been an inclusion of the “Push” web technology in the dissemination of EBM. This can be seen in the Patient Oriented Evidence That Matters (POEMS) that was initially published in the BMJ, but which is now part of the Essential Evidence Plus, and the more recent BMJ EvidenceUpdates service. The information provided are not only critically appraised by a panel of experts but are also reviewed for their relevance in clinical practice before being delivered by e-mail based on user pre-selected criteria.
Map of Medicine
The latest tool available to clinicians is called the “Map of Medicine”. It was initially developed as part of the national Connecting for Health agenda but has been recently converted into a privatised entity.
It is a web-based evidence-based resource that uses an interactive flow-chart interface for ease of use. It also has a built-in flexibility that enables the inclusion of specific local information.
The evidence is found through a systematic literature search and subjected to critical appraisals of its’ validity and relevance in current practise and is constantly updated as the evidence evolves. In addition, it also includes guidelines and criteria for specialist referrals in the care pathway.
By allowing the inclusion of local information, it would foster a feeling of ownership among the users and increase the likelihood of its use in daily practise. Work is also in progress to gain recognition of its use as part of Continuing Professional Development.
Other knowledge management tools
It is an exciting time indeed for the development and use of knowledge management tools. We have reached a stage of technological development that have led to a convergence in hardware, software, wireless networking and interface design that makes the access of EBM at the point of care14 September, 2014amless integration of these resources into the clinical workflow via an Electronic Health Care Record.
Development and integration of “Web-agent” technology may one day lead to intelligent search engines that would silently work in the background; " collecting", " appraising" and "structuring" the up-to-date evidence for each and every patient.
These personalised search agents would also be able to learn from its interaction with individual users and only look for information that matches the needs and experience of the user.
Although this may seem fanciful now, we do not have any choice but to continue to develop better search technologies in this “escalating arms race” with the continuing explosion of information and the subsequent information overload.
Although clinical guidelines have been used quite extensively in the past, they are rapidly being outdated by the pace and growth of biomedical knowledge which is currently approaching 5,000 articles per day.
The guideline development also needs to take into account all the views of its multi-disciplinary members and hence is subject to lobbying pressures from various groups. There are also the issues of the existence of multiple guidelines on the same subject that may have conflicting recommendations.
Guidelines by their nature cannot be specific to local needs, and hence are unlikely to be integrated into local practise wholesale. And because guidelines are developed for very specific topics only, we are again stuck in the quagmire of being unable to find the necessary information in the pile of guidelines in the ward or in the clinic.(17) This study illustrates the importance of having a single source of reference that is not only constantly updated but is also searchable for all topics.
Clinical expert systems, which are also known as Clinical Decision Support Systems (CDSS), are the other alternative source of information. Despite their sophistication and many years of development, they have not been widely used or accepted.
The reasons being that the usefulness of the system depends on the user’s ability to identify and use the relevant information produced; and ignore the irrelevant information that can also be produced. It may also lead to over-investigation or over-treatment in inexperienced clinicians who cannot differentiate between the two.(18)
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17 May, 2017