Rae-Ellen W. Kavey, National Heart, Lung, and Blood Institute
Frank Ascione, University of Michigan; Lisa Bero, University of California, San Francisco; Linda Burns-Bolton, U.S. Department of Veterans Affairs; Barry Carter, University of Iowa; Gray Ellrodt, University of Massachusetts; Pat Ford-Roegner, American Academy of Nursing; Arthur Garson, Jr., University of Virginia; Ada Sue Hinshaw, University of Michigan; Cato T. Laurencin, University of Virginia; Rona F. Levin, Pace University; Daniel Malone, University of Arizona; Bernadette Melnyk, Arizona State University; Nancy H. Nielsen, American Medical Association; Kimberly Rask, Emory University; Jon Schommer, University of Minnesota; Glen Schumock, University of Illinois at Chicago; Cary Sennett, American Board of Internal Medicine; Lee Vermeulen, University of Wisconsin; Lynda Welage, University of Michigan
Evidence-based practice (EBP) has been defined as “the integration of individual clinical expertise and patient preferences and values with the best available external clinical evidence from systematic research” (Sackett et al., 2000). Although healthcare professionals may believe that this is how they have always practiced, performance assessments indicate that this is not the case (McGlynn et al., 2003). A growing literature recommends the use of evidence-based management practices, but such recommendations are not consistently implemented. The behavior of healthcare professionals represents the critical juncture between the theory of evidence-based medicine (EBM) and actual EBP. Effective mechanisms that link knowledge development to the diffusion and adoption of that knowledge will be essential to promoting the use of EBM in clinical decision making.
In 2003, the Institute of Medicine (IOM) Committee on the Health Professions Education Summit developed a new vision for clinical education in the healthcare professions. The overarching goal is that “all health professionals will be educated to deliver patient-centric care as members of an interdisciplinary team, emphasizing EBP, quality improvement approaches, and informatics” (Institute of Medicine, 2003). The goal of this health professional sectoral strategy process is to support that vision, as it applies specifically to increasing use of EBM in clinical practice. The focus is on the delineation of strategies that will shift healthcare delivery away from the traditional physician-dominated practice and toward a concept of practice performed by interdisciplinary teams empowered to seek out and implement the best evidence for patient care. Such teams will have both the ability and expectation to continuously learn and change, through informed access to evidence-based clinical decision support, informatics, and clinical data repositories.
The potential scope of the sector includes all healthcare professionals. A minimal list would include physicians, nurses, nurse practitioners, physician’s assistants, pharmacists, social workers, dietitians, physical and occupational therapists, and medical technologists. This discussion uses physicians, nurses, and pharmacists as representatives of the healthcare professional sector; but the concepts articulated here are intended for potential application to all healthcare professionals. The remainder of this chapter describes the current state of EBP, identifies key activity categories, and proposes potential transformative initiatives for each of these three types of healthcare professionals.
The vision of physicians as members of teams in which each participant is empowered to seek out the best evidence for care is a new and powerful image. Achieving this vision will require profound change, but evidence-based health care will not occur without that change. Effective mechanisms that link knowledge development to the diffusion and adoption of that knowledge will be critical components in promoting the active use of EBM in clinical care. The broader dissemination of technologies that support the delivery of evidence-based care will clearly be essential; but the information collected for this report—summarized in the paragraphs below—suggests that the main issue here is not only technical but also cultural: commitment to the principles of evidence-based, team-directed, patient-centered care will require a fundamental change in what physicians understand to be their primary obligations as healthcare professionals. That change in culture and professional norms—from an emphasis on the physician as the knowledge expert to an emphasis on the physician as a team member whose role is
to access and interpret relevant, timely, and appropriate information for delivery to the patient in conjunction with all members of the healthcare team—will drive the acquisition of the tools required to implement a vision of evidence-based care.
The primary construct of patient-centric care—that patients themselves are central to the process and are actively engaged in self-education and management—is one that necessitates a major shift in how physicians are trained and how they practice. Without such changes in culture and professional norms, physicians will fail to capitalize on opportunities to acquire and deploy the knowledge and technologies essential to achieving that vision of patient-centric care.
The implementation of any process requires an assessment of the existing state of the field. The current practicing physician population in the United States includes just less than 600,000 individuals; 86 percent of physicians are primarily involved in clinical practice, with 50 percent in practices with four colleagues or fewer, and of that 50 percent, 20 percent are in solo practice (American College of Physicians, 2005). Active practitioners range from those who have just completed training to those whose formal education occurred as long as 40 years ago. Actualization of the concepts of both EBM and practice quality assessment is also closely linked to access to information technology (IT). The rate of use of IT support systems, from handheld computers to completely electronic medical record (EMR) systems, is continuously increasing in medical practice; but less than 25 percent of physicians currently use some kind of EMR and 40 percent use a handheld computing device to support their practice (Gans et al., 2005; Garritty and El Emam, 2006; Jha et al., 2006). Of note, the rate of EMR adoption is the lowest among physicians in smaller practices. In addition, training in EBP is also a relatively new concept, with the time dedicated to training in EBM varying with the specialty and the training program (Green, 2000). With such diverse ranges of individuals, baseline knowledge, technical support systems, and practice settings, any recommendations for change must be broad, flexible, and incremental.
What is less well known but what can perhaps be inferred from data on behavior is how physicians perceive the technologies that are relevant to the implementation of EBM, that is, whether they perceive them to be important to their efforts to improve patient care. Clearly, one must be concerned that the slow adoption of healthcare IT—and the push back that has been apparent among leaders in the healthcare professions regarding efforts to promote quality measurement and industrial approaches to quality improvement based on that measurement—reflects a prevalent attitude that the adoption of healthcare IT is not necessarily in the best interests of patient care (Audet et al., 2005). The shift to electronically based practice is expensive, particularly in a solo or small group practice setting. The
implementation of many IT practices can require major changes in clinical processes that can slow the delivery of care, especially during the early stages of their adoption. Promoting the use of technologies believed to be fundamental to the implementation of evidence-based care will have to address these issues to overcome practitioner resistance. Again, the most important set of activities in which the healthcare professional sector may have to engage may be related to changing that attitude.
Medical School Education
The process of integrating EBM into medical school education is already well under way. In 1999, the American Association of Medical Colleges identified the concepts of EBM as a critical objective for medical education (Medical School Objective Project Writing Group, 1999). As an intrinsic part of medical education, training in EBM provides individual physicians with critical search and appraisal skills for review of the medical literature, introduces the concept of continuous quality assessment as a routine of medical practice, and provides the basis for effective lifelong learning directly linked to patient care. Adoption of evidence-based recommendations optimizes the diagnosis and management of clinical conditions for which an evidence-based approach has been developed. One aspect of EBM that should make its adoption easier for current medical students is their nearly universal facility with IT as a routine part of daily life; maximizing this advantage should be considered in the development of changes in the medical school curriculum. From these precepts, medical school educators have introduced EBM into the medical school curriculum in a variety of ways. For example, innovative courses have transformed basic classes in epidemiology and statistics into intensely participatory discussions of cases designed to illustrate the principles of population health (Marantz et al., 2003). Preventive medicine has been integrated into clinical clerkships, and evidence-based decision making has become relatively standard during internal medicine rotations (Carey, 2000; Green, 2000). Evidence of the increased knowledge and use of EBM concepts in the first 3 years after medical school graduation is beginning to be reported; but as yet, there are few, if any, reports evaluating the use of EBM in posttraining clinical practice (Davidson et al., 2004; Dorsch et al., 2006).
Finally, assessment of medical students’ knowledge of population health and evidence-based decision making needs to be a requirement for medical school graduation. A review of content outlines and sample questions from the National Board of Medical Examiners published in 2003 indicates no formal content of this kind (National Board of Medical Examiners, 2003).
Beginning in 1999, the Accreditation Council for Graduate Medical Education (ACGME) Outcomes Project redesigned the curriculum for residency and fellowship training after graduation from medical school to focus on the outcomes of the training rather than program process measures (ACGME, 1999). The project defined six basic core competencies: medical knowledge, patient care, systems-based practice, professionalism, interpersonal/communication skills, and practice-based learning and improvement. Achievement of the last competency explicitly requires exposure to “investigation and evaluation of patient care practices, appraisal and assimilation of scientific evidence, and continuous improvement of patient care practices.” There is a timeline for implementation of this new approach to resident education: at this time, all residency training programs must have begun to provide learning opportunities in the six defined competency domains, with the requirement for full integration of the training in the competencies and their assessment by June 2011 (ACGME, 1999).
The ACGME standards set a critical goal to provide residents with a practical working knowledge of EBP during their residency training that will allow them to provide optimal patient care on the basis of the best available evidence. Reports of early approaches to meeting the ACGME standards provide models of how evidence-based theory and EBP can be integrated into residency training; these approaches include exposures in multiple disciplines (Bradt and Moyer, 2003; Rucker and Morrison, 2000).
Ross and Verdieck (2003) have validated that this kind of educational exposure increases residents’ knowledge of EBM and their use of EBM principles in practice during their residency training. Proof that this kind of training will be sustained into postresidency practice is not yet available, nor is evidence that such training will improve patient outcomes.
Education of Practicing Physicians
The challenge of increasing the practice of EBM among physicians in practice is formidable. Physicians represent a diverse group of individuals, not least because of the wide range of time from the completion of medical training to the present. For example, 18 percent of practicing physicians are between 55 and 64 years of age and completed medical school an average of 30 to 40 years ago (U.S. Department of Health and Human Services, 2003). Not surprisingly, the time that a physician has been out of residency training has been shown to correlate with a lower rate of adherence to evidence-based management and the greater use of tests and therapies with no proven benefit (Conway et al., 2006). Despite continuing medical education (CME), there will be many for whom the formal concept of EBM is
completely unknown. Nonetheless, winning the minds and hearts of practicing physicians will be essential in achieving universal EBP. One potential mechanism for achieving this is CME, the standard approach to continuous learning for healthcare professionals. Currently, physicians are required to accrue a defined number of CME credits annually to maintain hospital privileges, qualify for relicensure, or maintain specialty certification. However, despite the clear demonstration that the pure dissemination of information has a limited impact on behavior change among physicians, traditional lecture formats persist as the most common form of CME. Randomized controlled trials of educational interventions have shown that for physicians automated reminders, patient-mediated interventions, outreach visits, and the use of opinion leaders are more effective behavior change strategies than CME. Training on quality assessment in practice based on EBM-based quality assessment with pre- and posttraining practice audits has also been used effectively to increase knowledge and the rate of implementation of EBM (Dexter et al., 2001; Hunt et al., 1998; Kuperman et al., 1996). With this uneven landscape as the starting point, flexible innovative approaches to increasing evidence-based clinical practice will be essential.
Although current medical school students and trainees have high levels of access to and comfort with computers and IT, these levels are highly variable among all medical practitioners (Gans et al., 2005; Garritty and El Emam, 2006; Jha et al., 2006). To remain up-to-date with recent evidence for optimal care, physicians need easy and immediate access to Internet-based knowledge repositories. A variety of computer-based clinical decision support systems have been shown to improve clinician performance and patient outcomes (Hunt et al., 1998; Kuperman et al., 1996) and to specifically increase the rate of use of evidence-based guidelines (Dexter et al., 2001). However, physicians currently have limited access to such systems, and the initial investment and the technological support necessary to establish and maintain them are substantial (Maviglia et al., 2003).
Even with adoption of EMR systems, there is wide variation in the technical capabilities of these systems, with only 65 percent of the systems providing immediate access to clinical guidelines and protocols, and most of these have limited decision support capabilities. In addition, many of these systems do not include the essential ability to interrogate patient records for quality assessment and research (Gans et al., 2005).
Although the use of such systems may eventually become universal and the functional capacities of physicians are likely to improve, the transition to EMR alone does not increase the rate of use of EBP. It does, however, provide the critical infrastructure needed to facilitate EBP. Given the financial limitations inherent in small practice settings and the dominance of this mode of practice, external support will be needed to facilitate IT-supported practice for the majority of healthcare professionals. Therefore, at a mini-
mum, proposals to increase the rate of adoption of EBP must address both computerized and noncomputerized practice settings.
Finally, regulatory oversight for practicing physicians needs to be expanded to include standards of EBM practice, quality assessment and improvement, and continuous learning, which should be mandatory for maintenance of certification. This oversight is beginning to occur, especially in internal medicine, in which the American Board of Internal Medicine has developed evidence-based clinical performance measures for physicians (LaBresh et al., 2004). There are several different practice assessment options, each of which includes a World Wide Web–based self-evaluation as well as some form of formal practice assessment; successful completion of an assessment results in credits for both the maintenance of certification and CME.
Nursing is the largest of the healthcare professions, with nearly 3 million nurses in the United States, the majority of whom are practicing in hospital settings (U.S. Department of Labor, 2006). Registered nurses (RNs) are educated at various levels and receive associate degrees, hospital program-based diplomas, and baccalaureate degrees. Advanced-practice nurses (e.g., nurse practitioners and clinical nurse specialists) are educated through master’s degree and clinical doctoral programs, whereas nurse researchers are educated in doctor of philosophy and nursing science doctoral programs that place an emphasis on the learning of the knowledge and skills required to conduct rigorous studies that extend science and produce evidence to guide best clinical practices.
Nurses assume vital roles in the healthcare system, such as (1) providing high-quality direct patient care across the care continuum; (2) assessing and monitoring patients’ health status and outcomes; (3) planning, tailoring, implementing, and evaluating clinical interventions; (4) facilitating self-management strategies so that individuals achieve the highest level of health and adhere to prescribed treatments; and (5) promoting physical and mental health through patient education and anticipatory guidance. In addition, nurses are clinical researchers/scientists who lead interdisciplinary research teams in generating new knowledge and evidence to guide best clinical practices. They are also healthcare leaders and administrators who spearhead organizational change and systems improvements and teachers and mentors who prepare the next generation of direct care providers, educators, and nurse scientists.
Although federal agencies, professional organizations, healthcare leaders, and insurers have emphasized EBP as a key strategy for improving the quality of health care and patient outcomes, the majority of nurses do
not deliver evidence-based care (Institute of Medicine, 2003; Melnyk et al., 2005). A recent descriptive survey with a random sample of 1,097 randomly selected RNs from across the United States found that (1) almost half were not familiar with the term “evidence-based practice”; (2) more than half reported that they did not believe that their colleagues use research findings in practice; (3) only 27 percent of the survey participants had been taught how to use electronic databases; and (4) most reported that they did not search information databases (e.g., Medline and Cumulative Index to Nursing and Allied Health Literature [CINAHL]) to gather practice information, and those who did search these resources did not believe that they had adequate search skills (Pravikoff et al., 2005).
Numerous studies have identified major barriers to the use of EBP, including (1) inadequate education and knowledge in EBP, including IT; (2) weak beliefs about the value of EBP; (3) negative attitudes toward research; (4) misperceptions about EBP (e.g., a perceived lack of time to implement EBP); (5) a non-EBP culture in healthcare settings and few resources at the point of care, including appropriate tools and a formal structure; (6) competing priorities; (7) a lack of administrative support and incentives to change practice; (8) insufficient numbers of advanced-practice nurses to serve as EBP mentors to direct care staff; (9) various levels of educational preparation; and (10) the omission of EBP as a responsibility and a lack of accountability in clinical practice (Fineout-Overholt et al., 2005; Melnyk and Fineout-Overholt, 2005; Pagoto et al., 2007).
Recent anecdotal reports indicate that when nurses and healthcare professionals implement EBP, they feel more empowered and more satisfied in their roles as healthcare providers (Maljanian et al., 2002; Strout, 2005). These are important findings, because the nursing profession is facing the most severe personnel shortage in its history, with the current vacancy rate for RNs reported to be 8.5 percent (American Hospital Association, 2006). The demands on nurses as a result of this shortage have led to increasing reports of job dissatisfaction and an intent to leave the profession (Bowles and Candela, 2005). In a recent study, 23 percent of nurses intended to leave the profession, with another 37 percent uncertain of their future (Larrabee et al., 2003). Another recent report noted that the national average turnover rate for new nursing graduates is 35 to 60 percent (Zucker et al., 2006). High turnover rates are costly to the healthcare system and negatively affect patient outcomes (Aiken et al., 2003). Furthermore, an IOM paper, Keeping Patient’s Safe: Transforming the Work Environment of Nurses, stressed the importance of the simultaneous use of EBPs and the removal of the inefficient work of nurses as key strategies to obtaining a safe and satisfying practice environment (Institute of Medicine, 2004). Thus, in addition to improving the quality of care and patient outcomes, EBP may be a key factor in increasing job satisfaction and reducing nurse turnover rates.
Although RNs receive their foundational preparation through a variety of educational mechanisms (i.e., associate degrees, hospital program-based diplomas, and baccalaureate degrees), all educational programs need to cultivate a spirit of inquiry in their students and prepare them to be clinicians who practice EBM, appropriately leveling EBP-related knowledge, skills, and competencies on the basis of the level of educational preparation. A meta-analysis conducted in the late 1980s indicated that nursing interventions based on scientific evidence rather than steeped in tradition achieved better patient outcomes (Heater et al., 1988). Despite the findings from that meta-analysis, academic programs in nursing have been slow to incorporate the teaching of EBP. Nursing education at both the baccalaureate and the master’s levels has historically focused on preparing graduates to be the generators of research instead of the users of evidence who can efficiently translate research findings into practice to improve care, even though the American Association of Colleges of Nursing contends that nursing education is to prepare students to “use scientific knowledge in their practice” (American Association of Colleges of Nursing, 2004).
Research in nursing academic programs has also traditionally been taught in isolation and not as part of other nursing courses, and thus, students have failed to see the application of research findings to clinical practice (Burke et al., 2005). The tedious nature of the methods used to teach research and a lack of relevancy to real-time clinical situations have contributed to the pervasive negative attitudes toward research by practicing nurses and misperceptions that EBP is not feasible because of today’s healthcare environment and nursing shortage.
To prepare nursing graduates to be evidence-based clinicians, nursing school faculty must have the in-depth knowledge and skills needed to teach and model EBP. In a recent descriptive survey of 79 nurse practitioner educators from the National Organization of Nurse Practitioner Faculties and the Association of Faculties of Pediatric Nurse Practitioners, participants’ self-reported knowledge of EBP was high and they believed in the benefits of EBP as well as the need to integrate it into academic curriculums. However, the faculty responses on the survey indicated a knowledge gap in EBP teaching strategies. Furthermore, few of the faculty’s academic programs offered a foundational course in EBP. Additional findings from that study indicated significant relationships among educators’ knowledge of EBP and (1) their beliefs that EBP improves clinical care, (2) their beliefs that teaching EBP will advance the profession, (3) how comfortable they feel in teaching EBP, and (4) whether clinical competencies in EBP are incorporated into clinical specialty courses (Melnyk and Fineout-Overholt, 2008). Therefore, there is a tremendous need to equip academic faculty with in-depth knowledge and skills in EBP so that they can teach and model it for their students. A recent position statement from the National League for
Nursing (NLN) calls for new models of nursing education that will address demands for competencies in EBP. In that statement, the NLN reports that the “wide-scale transformation of education continues to be slow to materialize” (National League for Nursing, 2007).
Finally, the findings from a recent systematic review indicated that stand-alone classroom teaching of EBP or critical appraisal courses improved students’ knowledge of EBP but that only clinically integrated teaching improved their EBP-related skills, attitudes, and behaviors. Therefore, the consistent integration of EBP in the curriculum and skills building in EBP through an interdisciplinary approach to learning, including healthcare IT, throughout educational programs are necessary to prepare clinicians who will deliver evidence-based care upon entry into practice and throughout their careers (Coomarasamy and Khan, 2004).
In the current healthcare climate, nurses are challenged with heavy patient caseloads and understaffing in nearly all types of healthcare systems, including acute-care hospitals, home health care, primary care, correctional facilities, and long-term care settings. The typical profile for a practicing nurse as well as a faculty member in the new millennium is a 47-year-old individual who has not been educated in EBP or healthcare IT as part of his or her basic nursing curriculum (U.S. Department of Health and Human Services, 2004). These factors create substantial challenges for the rapid advancement of EBP in the nursing profession. Additionally, continuing education for nurses is not mandated in many states. In those states in which continuing education is required for relicensure, it is typically less than 25 contact hours every 2 years. Therefore, rigorous initiatives are necessary to transform and sustain an evidence-based approach to clinical care, including education in and access to healthcare IT, tools that enhance EBP, and a culture that supports this type of practice.
Even if healthcare providers are educated in and have the skills needed to implement EBP, without a culture that supports and provides the necessary resources for this type of practice, it is unlikely that EBP will be sustained. Leaders within healthcare organizations (e.g., chief medical and nursing officers), with the input of interdisciplinary healthcare professionals, need to create an exciting vision and strategic plan for EBP, as well as provide the culture and necessary resources to support it (Melnyk and Fineout-Overholt, 2005). The strategic plan must then be clearly communicated to all interdisciplinary healthcare professionals. Expectations for EBP should be set and integrated throughout the healthcare system’s philosophy and performance standards, with staff having accountability and incentives for meeting those standards.
Findings from previous studies have indicated that there are a number of facilitators of EBP in healthcare systems, including (1) healthcare providers’ knowledge and skills in EBP, (2) healthcare providers’ beliefs that
EBP improves care and patient outcomes, (3) healthcare providers’ beliefs in their ability to implement EBP, (4) EBP mentors who are skilled in EBP and organizational change, (5) administrative/organizational support, and (6) journal clubs and EBP fellowship programs (Fineout-Overholt et al., 2005a,b; Levin et al., 2007; Melnyk and Fineout-Overholt, 2005; Pagoto et al., 2007). Evidence from a recent survey also indicates that healthcare professionals who rate themselves higher on knowledge and beliefs about EBP are more likely to teach it to others (Melnyk et al., 2003). Therefore, to advance EBP, healthcare systems should implement educational and fellowship programs to enhance the EBP-related knowledge, beliefs, and skills of its staff; provide EBP mentors who can work directly with staff to implement EBP initiatives, such as journal clubs and EBP implementation/outcomes management projects; and provide the necessary administrative support and resources, including computers for the use of EBP at the point of care and healthcare IT systems that are user friendly.
Several conceptual models can guide the implementation of EBP in healthcare systems. Some models provide process frameworks for the implementation of EBP by individual practitioners. These include (1) the model of Stetler (2001), (2) the EBP model of DiCenso and colleagues (2005), and (3) the Clinical Scholar Model (Schultz, 2005). Other models are focused on the systemwide implementation of EBP, including (1) the Iowa Model (Titler, 2002), (2) the model of Rosswurm and Larabee (1999), and (3) the model of advancing research and clinical practice through close collaboration (Fineout-Overholt et al., 2005a,b; Melnyk and Fineout-Overholt, 2002). However, evidence has yet to be generated in the form of model testing or full-scale randomized clinical trials to support the majority of these models. Thus, studies of this nature are greatly needed.
Outcomes management is another key substantive area within EBP. The measurement of outcomes related to practice changes based on evidence is the final step of EBP and provides empirical support for the impacts that these changes have on patient outcomes and healthcare systems. The measurement of outcomes is key to influencing healthcare policy and facilitating the widespread adoption of best practices across healthcare systems.
Historically, the pharmacist’s role focused on the preparation, formulation, and distribution of drug products to the public. As drug formulations became more standardized and the manufacture of drug products gradually became the responsibility of the pharmaceutical industry, the role of the pharmacist shifted more to the safe distribution of the drug product, ensuring that the patient received the right drug in a timely manner. Over the years, the pharmacy profession has continued to evolve to one that is
responsible for drug use control and as a knowledge system focused on the distribution of drug products, resulting in the concept of “pharmaceutical care.” Pharmaceutical care involves the process through which a pharmacist cooperates with a patient and other healthcare professionals in designing, implementing, and monitoring a therapeutic plan that will produce specific therapeutic outcomes for the patient (Hepler and Strand, 1990).
Overall, the reorganization of pharmacy under the constructs of pharmaceutical care/medication therapy management has extended the roles of pharmacists. These new roles include the provision of medication therapy management and patient-focused services that are aimed at improving the therapeutic outcomes for Medicare beneficiaries who have multiple chronic diseases and who are receiving multiple medications (Bluml, 2005); the provision of disease state management; monitoring of drug therapies; participation in multidisciplinary clinical care teams; the provision of consultation on drug use; the provision of drug information and patient education; formulary management; and the provision of smoking cessation programs, disease awareness and education programs, and immunization programs (American College of Clinical Pharmacy, 2000; Bluml, 2005; Bluml et al., 2000; Bond et al., 2004; Chrischilles et al., 2004; Cranor et al., 2003; Doucette et al., 2006; Ellis et al., 2000; Fahey et al., 2006; Kaboli et al., 2006; Leape et al., 1999; McMullin et al., 1999; Schumock et al., 1996; U.S. Department of Health and Human Services, 2000).
In addition, many recent initiatives have focused on the development of physician-pharmacist collaborative management programs in which pharmacists work directly with physicians to optimize therapy (Hammond et al., 2003). Evidence throughout the literature shows pharmacists’ value to the healthcare team through the provision of patient-oriented services, with data showing improved patient outcomes and reductions in overall healthcare expenditures (American College of Clinical Pharmacy, 2000; Bhandari et al., 2004; Bluml, 2005; Bluml et al., 2000; Doucette et al., 2006; Ellis et al., 2000; Fahey et al., 2006; Kaboli et al., 2006; Kaushal and Bates, 2001; Leape et al., 1999; Logemann, 2003; McKenney and Wasserman, 1979; McMullin et al., 1999; Nester and Hale, 2002; Schumock et al., 1996). It is noteworthy, however, that pharmacy is the only healthcare profession reimbursed primarily for a product rather than for the provision of patient-specific services. Thus, it has been a challenge for the profession to implement the services described above more broadly without a payment model for drug therapy management or patient care. Clearly, with the extensive shift to patient-focused services, there is a greater need for pharmacists to use an evidence-based approach to clinical decision making. However, evidence demonstrating that pharmacists are knowledgeable in the constructs of EBP and are able to successfully apply evidence-based principles to the care of patients is lacking.
The implementation of EBP presents many challenges to pharmacists and other healthcare professionals. The majority of evidence on which clinical decisions are based continues to come from individual trials, but the quality of these trials varies. Although meta-analyses and preappraised resources have increased in numbers over recent years, they remain in their infancy. The potential lack of high-quality evidence with which clinically important issues are addressed is compounded by multiple issues, including (1) the priorities of funding agencies; for example, pharmaceutical companies may not align to address clinically important issues in a meaningful manner (i.e., many therapy clinical trials compare new therapies with a less optimal comparator, thus making it difficult to determine the precise role of the new drug in practice); (2) most existing evidence regarding drug therapy assesses efficacy under ideal circumstances rather than effectiveness in the general population; (3) a lack of publication of the negative findings of studies (publication biases), which is common in industry-sponsored trials; and (4) a lack of sufficient meta-analyses or a preappraised literature to facilitate decision making by end users (Bhandari et al., 2004; Feldstein, 2005).
Moreover, even with adequate sources of high-quality evidence and appraisal, the integration of this information into the decision-making process (i.e., the implementation of EBP) to improve patient care is often suboptimal. The literature contains many examples of high-quality systematic reviews, evidence-based guidelines, and so forth that could be used to recommend best practices; however, the implementation and adoption of these practices fail to achieve the desired goals. One such example is that even though evidence-based guidelines recommend that all individuals 50 years of age and older should undergo screening for colorectal cancer, screening rates remain extremely low (~30 percent) (Winawer et al., 2003).
Although many individuals hoped that technology such as computerized alerts would facilitate the implementation of evidence, recent data suggest that such alerts are often inadequate as sole tools to facilitate utilization of the evidence. For example, a recent evidenced-based review of 63 controlled studies of quality improvement interventions for hypertension noted that the median reductions in blood pressure were minimal for individual interventions such as audit/feedback (1.3 mm Hg), facilitate relay of clinical information (4.5 mm Hg), and patient reminder systems (2.8 mm Hg) were minimal compared with those achieved by organizational changes (10.1 mm Hg), which included physician-pharmacist collaborative management (14.1 mm Hg) (Walsh et al., 2006). A unique contribution of pharmacists would be for them to better integrate technology within the organizational structure of the healthcare system and provide EBM to improve patient care (Bailey et al., 2007). Overall, a greater emphasis needs to be placed on knowledge translation. Specifically, additional research is
needed to identify the best approaches to promoting the implementation and adoption of the evidence to achieve the desired clinical outcomes (e.g., what strategies improve the use of the evidence? how should patient preferences best be incorporated?). Such information on best approaches should then feed back into the educational paradigm to further promote EBP.
Pharmacy Core Education
The educational response to the expanded role of the pharmacist in health care has been to increase the level of education required for licensure. In 2000, the Doctor of Pharmacy (Pharm.D.) became the entry-level degree into the profession of pharmacy. The process of incorporating EBP training into the pharmacy curriculum is ongoing. For years, pharmacists have received extensive training in drug information as well as appraisal of the literature; and the most recent accreditation standards (July 2007), set forth by the Accreditation Council on Pharmacy Education, explicitly highlight the need to incorporate EBP, quality improvement, and informatics into the professional pharmacy education curriculum (Accreditation Council for Pharmacy Education, 2006). The training of pharmacists in EBP provides individual pharmacists with the critical skills that they need to formulate and revise clinical questions, efficiently and effectively search for information, critically evaluate the information, and integrate the patients’ values and preferences into the decision-making process. In addition, EBP introduces the concepts of the scientific method to investigating problems, continuous quality assessment and improvement, as well as lifelong learning.
To practice as a registered pharmacist, graduates from accredited schools of pharmacy must take a pharmacy licensing examination. Assessment of knowledge in evidence-based decision making needs to be a requirement for pharmacy school graduation; however, a review of the blueprint for the North American Licensure Examination indicates that competencies related to EBP or decision making are not included as core elements (National Association of Boards of Pharmacy, 2005). Of note, the Foreign Pharmacy Graduate Equivalency Examination, the licensing examination for pharmacists trained outside the United States, clearly identifies evidence-based decision making as a competency standard in its blueprint (National Association of Boards of Pharmacy, 2007).
Pharmacy Residency Training
Numerous accredited residency and specialty residency programs allow trainees the opportunity to gain additional knowledge and expertise after graduation from pharmacy school. All residency programs accredited or coaccredited by the American Society of Health System Pharmacists include
standards regarding EBP. For example, post-graduate year-1 residents must provide evidence-based, patient-centered care and collaborate with other healthcare professionals to optimize patient care (ASHP, 2006).
Graduate Programs and Postdoctoral Fellowship Training
Postdoctoral fellowship training programs, master’s degree programs, and doctoral programs in pharmacy emphasize the research skills needed for drug discovery, product development, the translation of basic science into clinical practice, health services research, and postmarketing surveillance research. One important aspect of EBP is the generation of new high-quality evidence. This aspect requires that individuals be adequately trained to conduct rigorous bidirectional translational research of type 1 (from bench to bedside) and type 2 (from bedside to adoption of best practices in the community) (National Institutes of Health Guide for Grants and Contracts, 2005). Pharmacy schools are unique in that they house individuals with an array of clinical and scientific expertise (i.e., expertise in medicinal chemistry, natural products, pharmacology, pharmaceutics, clinical sciences, pharmacoepidemiology, pharmacoeconomics) essential to translating a new drug molecule into a drug that may be used in clinical practice. Pharmacy graduate programs are diverse (e.g., medicinal chemistry, pharmaceutics, social and administrative sciences, pharmacology, and clinical sciences), but they all focus on building strong scientific inquiry skills.
Historically, most clinical pharmacy researchers have been trained through postdoctoral fellowship programs. Over the years several professional organizations (e.g., the American Association of Colleges of Pharmacy [AACP], Research and Graduate Affairs Committee, and the American College of Clinical Pharmacy Research Affairs Committee) have recommended that schools of pharmacy shift from a fellowship model to a graduate degree model for the training of clinical pharmacy scientists (American Association of Colleges of Pharmacy, 2007). In general, fellowships have suffered from a lack of consistent funding and disparate program completion criteria. Recently, the AACP Clinical Scientists Task Force recommended that there could be several pathways to the training of a clinical scientist, such as achievement of the Pharm.D. followed by the completion of a doctoral degree or dual degree programs (Pharm.D. and Ph.D., Pharm.D. and master’s degree) (American Association of Colleges of Pharmacy, 2007). Overall, the movement to train new interdisciplinary clinical scientists will facilitate the generation of high-quality evidence in the future and facilitate the translation of this information into clinical practice. In designing new programs for clinical scientists, one should consider the elements described in the next section.
Education of Practicing Pharmacists
Today, pharmacists make up the third largest group of healthcare professionals in the United States, with approximately 200,000 pharmacists in active practice (U.S. Department of Health and Human Services, 2000). The expanded roles of pharmacists plus the additional need to provide medicines to aging patients have resulted in an increasing need for registered pharmacists, the shortage of which is projected to be as high as 157,000 by 2020 (Cooksey et al., 2002; Knapp, 2002; U.S. Department of Health and Human Services, 2000).
Pharmacists represent a diverse group of healthcare professionals. Thus, the challenge of increasing the rate of adoption of EBP by pharmacists is formidable. Pharmacists not only practice in a diverse array of settings but also differ according to their educational backgrounds as well as the time since graduation or postdoctoral training. For example, the U.S. Department of Health and Human Services (2000) estimated that in 2000 approximately 30 percent of pharmacists were between 51 and 65 years of age and had completed their formal pharmacy education about 30 years earlier.
Although pharmacy is practiced in a wide variety of settings, the majority of pharmacists practice in a community setting (U.S. Department of Health and Human Services, 2000). Potential barriers to pharmacist delivery of evidence-based care in these settings include a lack of education and training in EBP; attitudes and misperceptions regarding EBP (i.e., a perceived lack of value or relevance); a lack of administrative and institutional support; insufficient time; a perceived lack of evidence; a lack of relevant patient data; and logistical issues, including a lack of resources to effectively retrieve high-quality evidence or a lack of infrastructure to support EBP (Pagoto et al., 2007). For example, in the community pharmacy setting, most pharmacists face increased patient volumes, increased numbers of prescriptions to be filled, staff vacancies, and increased administrative duties (10 to 20 percent of their time is spent dealing with third-party payers and formulary issues), all of which may detract from EBP (U.S. Department of Health and Human Services, 2000). In addition, pharmacists practicing in the community setting may lack adequate training in EBP, may not have access to searchable databases or preappraised information, and may be constrained by the environment and a lack of privacy to discuss issues and preferences with patients.
Engaging all pharmacists in EBP will require aggressive educational campaigns, which may be accomplished through continuing education (CE) programs as well as by making such training a requirement for existing specialty certifications. Most state boards of pharmacy require practicing pharmacists to undergo CE for licensure; although the precise amount and type of CE varies among the states, it is generally about 30 hours every
2 years. Pharmacists obtain CE through a variety of mechanisms, including through online web-based programs; by reading published CE articles and completing self-assessment questions; and by attending live CE programs often offered or sponsored by professional organizations, pharmaceutical industry, schools of pharmacy, or healthcare organizations. CE for pharmacists is undergoing a shift to a continuing professional development model, which embraces the concept of life-long learning. The continuing professional development model is self-directed, practitioner centered, and outcomes based and emphasizes the importance of practice-based learning. Use of this model may be a strategy by which EBP may be enhanced.
Increasing the adoption of EBP by practicing pharmacists will require extensive educational training. In addition, cultural changes in the delivery of health care will be necessary. The ultimate goal is to enable healthcare professionals to work together as members of an interdisciplinary team to integrate their clinical expertise and patient preferences and values with the best available external clinical evidence from systematic research to optimize clinical decision making.
Cultural Change and Education
The primary shift to EBP will require its integration into the curriculum throughout the following areas of formal education of all future healthcare professionals:
core education, in partnership with medical schools and the American Association of Medical Colleges, nursing schools, pharmacy schools, and so forth;
postgraduate training programs and internships, in partnership with academic medical centers and ACGME, plus residency review committees, nursing and pharmacy schools, and so forth; and
required competency, in partnership with licensing organizations, including the National Board of Medical Examiners, specialty and subspecialty certification boards, and state licensing boards; the National League for Nursing Accrediting Commission; the Commission on Collegiate Nursing Education; and the National Council of State Boards of Nursing.
A multifaceted approach to the education of practicing healthcare professionals to promote the universal adoption of EBP will require
a national public education campaign to educate all healthcare consumers,
individually directed continuous learning as an active concept in partnership with professional societies and in existing CME settings,
the use of improved patient care as the incentive for specific training in the use of evidence-based data,
regulatory oversight to mandate education in EBP—in partnership with state licensing organizations and specialty and subspecialty boards), and
interactions with professional organizations to develop educational programs to support evidence-based guidelines.
Systems Change in the Practice Setting
Changes to the healthcare practice setting will be important for the incorporation of EBP into the practices of healthcare professionals. The following describes some of these changes:
With healthcare professionals being the critical lynchpin in the delivery of evidence-based care, improved user-friendly clinical decision support systems are essential.
Changes to the healthcare culture are essential to support EBP.
To involve healthcare professionals in routine EBP, universal rapid access to medical knowledge and clinical practice guideline repositories in all clinical practice settings is necessary.
Continuous quality improvement mandates the ability to interrogate practice records for self-assessment, quality assurance, and research.
To realize universal evidence-based care, the use of EMRs must be universal.
The availability of a common IT vocabulary and interoperable technologies is essential to maximize the benefits of EMRs.
Increased Body of Evidence-Based Knowledge
To achieve the vision of universal EBP, a greatly expanded inventory of evidence-based guidelines and recommendations is needed. This can be done by:
generating medical evidence with existing patient care data by involving healthcare professionals as data generators as a standard part of care delivery,
increasing the rate of formal participation of healthcare professionals in practice-based research by making locations for participation readily accessible,
rigorously evaluating the outcomes of EBP to foster the adoption of evidence-based recommendations, and
increasing the rate of adoption of evidence-based guidelines by performing research on methods that can be used to enhance the translation of evidence into clinical practice.
LEADERSHIP COMMITMENTS AND INITIATIVES
Proposed Initiatives in Core Education
Critical concept: Incorporate precepts of population health; evidence-based knowledge and skills training; and quality measurement, improvement, and outcomes management.
evidence-based review methodology,
principles of epidemiology,
explicit training in searching the literature and evaluating the evidence found,
training in database interrogation, and
training in the basics of clinical research.
the concepts of quality measurement and improvement through the use of routine patient data and through audits and reviews of practice results, as illustrated routinely during clinical rotations;
continuous access to medical knowledge and clinical guideline repositories;
modeling of evidence-based decision making by faculty with knowledge and experience in EBP; this will often require faculty to have training and experience in EBP;
exposure to innovative cross-disciplinary curriculums that train integrated teams of healthcare professional faculty and students;
routine exposures to interdisciplinary team care; this will require integration with other healthcare professionals;
the concept of continuous learning, which should be explicit in the curriculum and implicit in clinical rotations, as modeled by faculty;
explicit training in finding and evaluating materials for patient education;
exposure to clinical research and opportunities to participate in clinical research; and
training in the critical appraisal of the medical literature.
The vertical integration of accreditation organizations should be addressed so that core competencies in EBM are specifically reinforced in clinical training. In addition, healthcare professional students should be assessed for their competence in preventive medicine and evidence-based knowledge and decision making before they graduate.
Proposed Initiatives in Graduate Clinical Education
As part of their graduate clinical education, students should routinely be exposed to interdisciplinary healthcare teams that use evidence-based methods to deliver care. Means of accomplishing this are described below.
Based on defined competencies, support training in EBP as a core competency in all clinical training programs.
Make best practices from programs like education innovation projects available as models for training programs.
Work with certification boards to introduce the skills necessary for EBP. This work should be aligned with expectations in the post-graduate period for the demonstration of competency in EBP.
Integrate the concept of continuous learning in the curriculum for clinical training both explicitly and implicitly, as modeled by the faculty.
Integrate and model the concepts of quality measurement and improvement, systems-based practice, and team-based care into clinical training.
Evaluate the students’ knowledge of evidence-based decision making in certifying examinations and state licensure standards.
Proposed Initiatives in Postgraduate Education and Culture Change
Critical Concept: Changing the way health care is delivered will require broad educational initiatives that include the general public as well as practicing healthcare professionals.
Public Education Campaign: Use the media to introduce the concept and benefits of EBP to the public in general and practicing health professionals, in particular:
Educational segments in the media and packaged for healthcare settings should feature health professionals in the educational role.
Studies indicate that a majority of Americans get their health information from the media; questions from patients will represent a powerful reinforcement of EBP.
For healthcare professionals, continuous learning can be achieved in a variety of ways:
Use healthcare professional leaders and professional organizations to establish lifelong learning as a professional obligation.
Interact with professional societies to educate the membership about EBP through society journals, meetings, and educational programs.
Develop and market a model CME program for use at the community level to introduce the principles of EBP. The program will include (1) the concepts of evidence-based decision making, (2) examples of healthcare professional and patient tools that facilitate EBP, and (3) a project for CME credit consisting of a self-scoring assessment of practice adherence to best practice recommendations. The program can be made available to hospitals, medical centers, practice groups, and professional organizations.
Expand traditional CME and continuing education units to include the use of web-based EBP training by providing extra credit CME for EBM training to increase exposure.
Support incentives to increase the rate of implementation of EBM.
Provide oversight by
requiring licensure standards to include knowledge of EBM;
assessing a healthcare professional’s knowledge of EBM in specialty and subspecialty board examinations as a component of the initial certification and the maintenance of certification; and
including specific training in EBM and reporting of EBM as a performance standard for licensure and maintenance of certification.
Proposed Initiatives in Practice Setting Systems Change
Table 6-1 provides examples of some of the initiatives already in place in the clinical practice setting. The following describe other means of changing the practice setting:
Endorse the investments made by government agencies, insurers, and hospitals in the acquisition of EMRs in hospitals, medical
TABLE 6-1 Sample Initiatives Already in Place
centers, and practices as a way to jump-start their adoption by healthcare professionals.
Establish healthcare cultures that support the systemwide implementation and the sustainability of EBP, including resources at the point of care, EBP mentors, and time for healthcare professionals to engage in EBP as routine.
Support the development and implementation of a common vocabulary and interoperable technology to optimize the use of patient data both in practice and for assessment of evidence-based guideline implementation, and provide feedback to healthcare professionals.
Recommend the provision of EBM guidelines in an IT format compatible with all forms of EMR as well as in paper versions for healthcare professionals who do not yet routinely use electronic technologies.
Work with professional practice organizations to develop guideline implementation packages, including clinical practice and patient education tools, to be released with all major guidelines.
Support the provision of add-on modules (electronic and paper based) to efficiently update existing evidence frameworks.
Support the study of regionalized processes for the provision of IT support to small practices, such as collaborative practice models, virtual large group practices, public health-based support, or regionalization through interaction with academic medical centers.
Involve healthcare professionals in the design and development of IT support systems to reduce redundant data entry, screen changes, and forced recommendation practices. This will serve the dual role of making such systems directly responsive to the needs of practicing healthcare professionals and of creating leaders who will advocate for EBM and IT-supported care in their home communities.
Proposed Initiatives in Use of Medical Evidence Generation as Standard Care
Educate healthcare professionals about how existing information from patient care can be used as clinical research data.
Increase opportunities to participate in practice-based research to expose healthcare professionals to the means of generating the science base from which evidence-based recommendations are developed.
Involve practicing healthcare professionals in the development of research questions with direct clinical practice.
Provide specific opportunities for solo and small group practice and community hospital settings to participate in clinical practice research networks.
Support formal evaluations of the impact of EBP on clinical outcomes.
Seek mechanisms for financial support of participation in registries and research databases, for example, the American College of Surgeons National Surgical Quality Improvement Program.
Support EMR development to allow inquiries of the patient database for clinical research.
Collaboration of Healthcare Professionals Sector with Other Sectors
Interact to expand the clinical base from which evidence is generated to include a wide range of practice settings and observational data.
Support the federal funding of research on outcomes from the implementation of EBP.
Encourage research on the dissemination of EBP and the implementation of best practices.
Release major new guidelines simultaneously with the findings of a funded research trial for evaluation of defined practice outcomes.
Support the development of evidence-based guidelines in areas in which few or none exist (e.g., for patients with multisystem diseases and for the screening and treatment of children and adolescents for whom the chances of positive outcomes of a disease process are remote).
Several systematic reviews have documented the relatively small number of studies and the poor quality of research evaluating the effectiveness of interventions to increase the rate of use of EBP. Support for research into innovative approaches to changing the behavior of healthcare professionals with rigorous outcome evaluation is essential.
Work with IT developers to develop a common vocabulary and interoperable technologies to allow information sharing.
Interact with IT developers to improve EBM guideline interfaces to reduce redundant data entry and to screen changes and forced recommended practices, and provide areas for documentation for exceptions.
Include healthcare practitioners in the design and development of IT support systems.
Support the concept of the use of observational patient data as evidence for the healthcare system.
Encourage the development of patient materials to support consumer adoption of evidence-based health concepts and practice.
Support the development of robust methods to include patient values and preferences in complex decision making.
Encourage the use of performance feedback to adjust rates.
Endorse industry support of a transition to EMR with robust decision support at the point of care.
Support payer endorsement and the support of professional efforts to promote changes to the medical culture.
The adoption of EBP, including the shift to patient-centric care, will require nothing short of a transformation of current medical practice. In this transformation, healthcare professionals can be described as the critical transition point between current healthcare practice and the delivery of evidence-based care. This chapter on the healthcare professionals sector has identified a number of model initiatives that are already under way in a variety of settings to support this process. The chapter has also highlighted key actionable items that will further support the initiation of change. However, to truly make this kind of culture change possible, sustained effective leadership will be essential. To that end, we propose the appointment of an EBM Interdisciplinary Healthcare Professionals Advisory Panel to interact with the leadership at the IOM. The panel would serve as the voice of the healthcare professionals sector in education, practice, and regulatory oversight. The panel would be charged with establishing critical initial steps; identifying benchmarks to define progress; and developing future initiatives in education, practice, and regulatory oversight to sustain the process of adoption of EBM as it evolves. The creation of this panel would represent a new coordinated starting point for an integrated shift to EBP for the healthcare professionals sector.
Proposed Panel Format
We propose that the members of the panel play roles in education and in the practice setting and that they also have an oversight role. In the area
of education, leaders in the undergraduate and postgraduate education of healthcare professionals would be charged with the development and implementation of a coordinated set of strategies that would support lifelong learning in EBP throughout the healthcare professions’ education. Their initial role would be to consult in development of the EBM public education campaign. Proposed members could come from among the following groups: ACGME; American Academy of Nursing; American Association of Medical Colleges, including the Council of Deans; American Boards of Internal Medicine, Pediatrics, Family Practice, Surgery, and so forth; Commission on Collegiate Nursing Education; National Council of State Boards of Nursing; National League for Nursing; National Organization of Nurse Practitioner Faculties; and professional societies such as the American Academy of Pediatrics, American Association of Colleges of Nursing American College of Cardiology, American College of Pharmacy, American College of Surgeons, and Society of Thoracic Surgeons. IT developers, health practitioners, and leaders from the whole range of healthcare settings and professional organizations would be charged with working together on the design and development of support for EBP, including the development of a culture that supports EBP. Health insurance providers and healthcare regulators would be charged with the development of incentives to facilitate practice change.
Representatives from all those groups involved in the regulation and oversight of competence at all levels of healthcare professional training and practice would be charged with ensuring the vertical integration of competencies in EBM throughout basic and clinical training and postgraduate certification. Regulatory groups from which potential members would be selected include the National Board of Medical Examiners; ACGME; specialty and subspecialty boards; and state medical licensing systems for physicians, nurses, and pharmacists.
Summary: Healthcare Professionals
This chapter has outlined a strategy that can be used to increase the training of new healthcare professionals and those already in practice in EBP, improve IT support for EBP, enhance healthcare system cultures that support EBP, and increase the rates of participation of healthcare professionals in medical evidence generation as standard care. The chapter has also described specific initiatives that address this dual strategy at each stage of training or practice and has provided examples of benchmark programs that address aspects of these priorities. The use of a public information campaign as a way of introducing all practicing healthcare professionals and the American public simultaneously to the concepts of EBP, with reinforcement by the use of CME, educational incentives, and feedback from inquiring
patients and the development of partnerships with existing educational, IT, and practice research organizations will be important steps in supporting routine EBP, something that is already under way in many settings.
This review indicates that current models of excellence can be used to increase the rate of implementation of EBM. Whenever possible, these should be used to enhance this process. A combination of support for the required technology, the provision of rewards for improved performance, the provision of regulatory oversight, and increased participation in the generation of clinical research data are proposed as the most effective ways to sustain progress toward this important goal. Finally, appointment of an EMB Interdisciplinary Healthcare Professionals Advisory Panel is recommended as the critical first step in providing sustained leadership for initiation of the process needed to maximize the adoption of EBM in clinical practice.
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