Home » Research » Medical Knowledge Management

Evolution of Healthcare

J.A. Muir Gray [1] summarized the evolution of evidence-based healthcare in three different steps:

  1. Doing things cheaper: during the 1970s the increasing financial pressure on the national healthcare systems forced the research for reducing economic cost per case: healthcare was to be delivered in the shortest time, in the least expensive environment, by the least expensive professional, using the cheapest drugs or equipment sufficient to ensure effectiveness and safety. In one word: efficiency was the main relationship between inputs and outcomes. Economic evaluation studies and efficiency indicators begun to appear in the healthcare literature.
  2. Doing things right: during the 1980s, besides efficiency, there was a new imperative, the improvement of the healthcare delivery quality. As patients become more informed, more assertive and better organized, their expectation increased. Putting together the two paradigms, doing the things cheaper and doing the things better, fosters the new paradigm of doing things right.
  3. Doing the right things right: in the last decades the overall objective in healthcare is to do more good than harm. The key factor is the level of scientific evidence which support a medical action. This level is determined by the quality of the research on which the evidence is based.
Helath Care Evolution by Gray

Evidence Based Medicine

Evidence based medicine (EBM) is the

"conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients" [2].

The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens, as determined by clinical trials. External clinical evidence may both invalidate previously accepted diagnostic tests and treatments and replace them with new ones that are more powerful, more accurate, more efficacious, and safer.


Clinical Practice Guidelines

One of the main tools of EBM is represented by the Clinical Practice Guidelines (CPGs). CPGs are a means to improve the quality of delivered health care:

Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances
(Institute of Medicine, 1992).

CPGs are one of the key point of the EBM [3] referring to the management of individual patients through individual clinical expertise integrated with the judicious use of current best evidence from clinical care research. CPGs are a good example of KM, where the process of systematic review of the scientific literature is a source of knowledge to be integrated into and complemented by local, practice-based evidence for individual and site-specific clinical decision making.

There are several official organizations publishing CPGs with the aim of diffusing them within the medical community. Most of them offer CPGs on the web in textual format with some useful hyperlinks. One of the most important organization providing CPGs access online is the National Guideline Clearinghouse (NGC). Through the website it provides access to CPGs resources through a list organized by pathology or through searching criteria. The NGC mission is to provide physicians, nurses, and other health professionals, health care providers, health plans, integrated delivery systems, purchasers and others an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further their dissemination, implementation and use.

Key components of NGC include:

Level of Evidence and Strength of Recommendation »



References

[1] J.A Muir Gray
Evidence-based Healthcare: How to Make Health Policy and Management Decisions
Churchill Livingston, 1997

[2] L Sackett, William MC Rosenberg, JA Muir Gray, R Brian Haynes, W Scott Richardson
Editorial from the British Medical Journal
BMJ 1996; 312: 71-2

[3] Sim I, Gorman P, Greenes R, Haynes RB, Kaplan B, et al.
Clinical decision support systems for the practice of evidence-based medicine
Journal of the American Medical Informatics Association 2001; 8(6):527-34.