EBP &HI Emergency medicine&CC Nursing

Evidence Based Practice
Adamu Takele (MPH)
Nov/2020
02/13/2021 1
Introduction to Health Informatics
Terminology
 Health??
 Informatics:- the application of information technologies to
optimize the information management function within an
organization.
 IT is the study, design, development, implementation, support
or management of computer-based information systems.
Terminology
 Information Science is an interdisciplinary science primarily

concerned with the collection, analysis, classification, storage,
retrieval and dissemination of information.
 Computer Science is the study of the theoretical foundations
of information and computation and of practical techniques
for their implementation and application in computer
systems.
Health informatics
 Health informatics, Health care informatics is the
intersection of information science, computer science,
and health care.
 Health informatics tools include not only computers but
also clinical guidelines, formal medical terminologies,
and information and communication systems.
Some Sub-domains of Health Informatics
 Public health informatics
 Clinical informatics
 Medical Informatics
 Nursing informatics
 Dental informatics
 Bioinformatics
 Veterinary informatics
 Pharmacy informatics
 Telemedicine, etc…
Reading assignment
Search and read about the definitions for each sub-domains of Health
Informatics
The Information Pyramid
Type3
Strategic Information
Type 2
Tactical Information
Type1
Operational Information
6
1.Operational information
 This is information needed by those at the bottom of the

corporate hierarchy.
 It is detailed information relating to the day-to-day
running of the divisions of the corporation.
 Within the health care area this can be considered to be the
few clinical, and many administrative, systems that exist in
health facilities.
2.Tactical Information
 This is the information needed by those part-way up the
corporate hierarchy (who will usually be the managers of
the ones at the bottom)
 It is not as detailed as type '1' information.
 Support for day to day management.
 In fact, it frequently summarizes it (by group, perhaps, or
over time period).
 For this reason, it is often termed derived data, and the
systems which provide it are termed feeder systems.
8
3.Strategic Information
 This is information needed by those at the top of
the corporate hierarchy.
 Support for strategic decisions
 It is highly abstracted and summarized
9
Information cycle
 Information Cycle is a diagrammatic way of
looking at information and enables you to see the
links between the different phases: collecting,
processing, analyzing, presenting, interpreting and
using information.
10
Data handling processes in the info cycle
Tools:
Collection Client Cards
Tally Sheets
 Indicator based essential dataset Registers
 Data elements - std. definitions

 Data sources & tools defined
Use of Information  Data capture streamlined
Tools:
Programme Management
 Regular review of data Planning Processing Tools:
Budgeting
 Relate to operational plans Collation tools
Validation rules
 Monitor service coverage & quality Data flow  Collation
 Data quality checks (manual)
Tools:  Data validation (computer)
Interpretation Explore
Ask questions
Tools:
Research
Feedback Indicator formulas
 Making sense of information Analysis
 Possible interpretation
 Explore
Presentation
Tools:
Tables
 Indicators
Graphs
Discussions
 Flow of information Feedback
 Format of tables, graphs & reports

 Feedback mechanisms
Data Collection
Determine what data to collect

 All data collected must have a purpose.
 The information that we collect routinely should be
information that is essential to know and to take action
 The right information to the right person at the right
time and in the right way.
12
The Minimum/Essential dataset
 Routine HIS should only contain information that is essential
to provide good health service.
 The raw data required to generate this information is called
EDS (MDS)
 EDS is the minimum amount of data that needs to be collected
 WHY? For effective management of services (improving coverage &
quality)
 HOW? Routine data collection
13
Relevant data - EDS
. . . determine “must know” information needs
Must know – Should know –

info essential info not essential,
for but useful
management
Must Know
Should Know
now
Nice to know – info Nice to Know tok
not required, but r ous
e
interesting
ang
D
Characteristics of Good Data Quality
Correct
no mathematical errors
(validation rules)
Complete
submission by all (most) reporting facilities
all data items reported on (value filled in)
Consistent
data within normal ranges
Common problems with data
Large gaps
Unusual month to month variations
Inconsistencies – unlikely values
Duplication
Data present where there should not be
Data entered in wrong boxes
Math problems – poor calculation
Typing errors eg. Age 8888 for 88 year
Introduction to eBp?
Learning Outcomes
At the end of this lecture, you should be able to:
•Describe concepts of evidence based practice
•Apply Steps and processes of evidence based practice

•Demonstrate evidence searching techniques
•Demonstrate evidence searching tools and databases
•Appraise scientific evidence
02/13/2021 Adamu Takele (MPH) 18

What is Evidence Based Practice
 EBP is “the careful, clear and wise use of current best

evidence in making decisions about the care of the
individual patient.
 It means integrating individual clinical expertise
with the best available external clinical evidence
from systematic research.” (Sackett D, 1996)
Cont. …..
EBP is a process by which clinical decisions are made
using:
Best
Best available research evidence Evidence
Clinical expertise Patient

Values/Local
Clinical
Expertise
Conditions
Patient preference and values
 The best research evidence is usually found in clinically
relevant research that has been conducted using sound
methodology. (Sackett D, 2002)
20
WHAT IS THE BASIS OF YOUR
MEDICAL PRACTICE?
(Check all that apply)
A. Training, clinical experience and consultation with

other professionals
B. Convincing evidence (non-experimental) from

articles, case reports, product literature, etc.
C. Preferences of the patient
D. Active search of Randomized Controlled Trials,

Systematic Reviews, Meta-Analysis Reports
MEDICAL PRACTICE?
A. Training, clinical experience and consultation

with other professionals


Systematic Reviews, Meta-Analysis Reports
Institute of Public Health
BUT… Past knowledge and practice might be
outdated or inadequate

MEDICAL PRACTICE?

other professionals


Systematic Reviews, Meta-Analysis reports
BUT… This evidence may be
biased, outdated, incorrect, or not
applicable to your patient
JOURNALS (1987 to
present)
ARTICLES ADVERTISEMENTS
WHAT IS THE BASIS OF
YOUR MEDICAL PRACTICE?
A. Training, clinical experience and

consultation with other professionals
B. Convincing evidence (non-experimental)

from articles, case reports, product
literature, etc.
Mutual
MutualRespect
Respect++Shared
SharedGoals
Goals==
C. Preferences of the patient Better
BetterCooperation
Cooperationand
and
Compliance
Compliance
D. Active search of Randomized Controlled
Trials, Systematic Reviews, Meta-Analysis
reports
The patient should be involved in
all important decisions
But this is NOT always an
easy task!

And conflicts WILL occur!
No salt? I WON’T take that
Lose weight? medicine… The side
effects are But doctor, I
Forget it!
DO want to have
Justofgive
Institute me aHealth INTOLERABLE!
Public children!
pill!

And conflicts WILL occur!
No salt? I WON’T take that
Lose weight? medicine… The side
But doctor, I
Forget it! effects are
Justofgive me aHealth INTOLERABLE! DO want to have
Institute Public children!
pill!

Education about current alternatives and
risks is often needed… for both the
Patient and the Doctor!
Wow… Yes, I’d like to try
I’ll discuss those
I never knew that that new
risks with my
high blood medication!
Institute of Public Health husband.
pressure could
be so dangerous
at my age!

Education about current alternatives
and risks is often needed… for both the
Patient and the Doctor!
An important rule in evidence based
medicine
 It starts with the patient and ends with the

patient
 The patient’s preferences MUST be

considered
MEDICAL PRACTICE?
A. Training, clinical experience and consultation with other

professionals
B. Convincing evidence (non-experimental) from articles, case

reports, product literature, etc.
D. Active search of Randomized Controlled Trials, Systematic

Reviews, Meta-Analysis reports
But… A practice based exclusively on
science and math is effective only if
yourHealth
Institute of Public patients are robots or clones!
Don’t forget to allow for individual

human differences
and personal preferences!
MEDICAL PRACTICE?
If you checked all 4 items…

other professionals
B. Convincing evidence (non-experimental) from articles,

case reports, product literature, etc.

You are practicing EVIDENCE
BASED MEDICINE/Practice!
A. Training, clinical experience and consultation

with other professionals


OPTIONAL
COMPONENTS TO BE PATIENT
ADDED BY THE PHYSICIAN
Values, Preferences
Concerns,
Expectations
Life predicament
HUMILITY CHARITY
Non- EBM is not
authoritarian a required
practice practice
EBP (yet)
PHYSICIAN
Training INFORMATION
Expertise Clinically relevant
Continued Learning ENTHUSIASM Proven by research
Demand for proof Challenge, Current, up to date
Variety,
Change
Why we need EBP?
 To improve care
 To bridge the gap between research & practice
 “Kill as few patients as possible” (O. London)
 A new treatment might have fewer side effects.
 A new treatment could be cheaper or less invasive
 A new treatment may be necessary in case people develop resistance to existing
therapies, etc.
 To keep knowledge and skills current (continuing education)
 To save time to find the best information
37
What are some barriers for EBP?
 Overuse, underuse, misuse of evidence
 Time, effort & skill needed
 Access to evidence
 Pressure by senior clinicians
 Environment not supportive of EBP
 Poor decision making
The Five step EBP Process
1. ASK: Formulate an answerable clinical As
Ass k
question ess
2. ACCESS: Track down the best Evidence

Acc
3. APPRAISE: Appraise the evidence for its ess
validity and usefulness

Ap
4. APPLY: Integrate the results with your ply
Ap
clinical expertise and your patient prai
se
values/local conditions
5. ASSESS: Evaluate the effectiveness of the
process
ASK
 Converting information need into a clinical question
 PICO: Developing the answerable clinical question
 PICO stands for
 Patient
 Intervention
 Comparison
 Outcome
PICO is a way to organize a well built and answerable

clinical question
Background and Foreground questions
 Background questions : concerns general knowledge

(What do I know about this?)
Often these questions can answered by books
Example:- How do you treat heart failure?
 Foreground questions:- Specific information or specific knowledge
questions
These questions best suited for PICO question
Example:- In adults with heart failure, would adding warfarin to
standard therapy reduce thromboembolism?
PICO
P = Patient, population or problem
 (Who are the patients or populations? What is the disease?)
I = Intervention
(What do you want to do with this patient (e.g. treat,
diagnose, observe)?
C = Comparison intervention
(What is the alternative to the intervention (e.g. placebo,
different drug, nothing?)
O = Outcome
(What are the relevant outcomes (e.g. morbidity, mortality,
death, complications)?
A GOOD QUESTION…
• Is focused and relevant

• Provides clear communication
• Clarifies your goal or need
• Will reduce the amount of time needed to obtain
the answer
Asking the Well Built Clinical Question
 Assess the patient:

 Start with the patient– a clinical problem or
question arises from the care of the patient
 Ask the question:
 Construct a well built clinical question derived
from the case
02/13/2021 Institute of Public Health 44

PICO
 It is an anatomy of a good clinical question
 PICO is a mnemonic that helps one remember the key components
of a well focused question.
 The question needs to identify the key problem of the patient (P)
 what treatment or tests you are considering for the patient (I)
 what alternative treatment or tests are being considered (if any)(C)
and
 what is the desired outcome to promote or avoid (O).
PICO
 P= Patient Problem:
 How would you describe a group of patients similar to yours?
 What are the most important characteristics of the patient?
 This may include the primary problem, disease, or co-existing
conditions.
 Sometimes the gender, age or race of a patient might be relevant to
the diagnosis or treatment of a disease.
PICO
I= Intervention, prognostic factor or exposure:

 Which main intervention, prognostic factor, or exposure are you considering?
 What do you want to do for the patient?
 Prescribe a drug?
 Order a test?
 Order surgery?
 Or what factor may influence the prognosis of the patient - age, co-existing
problems, or previous exposure?
PICO
C= Comparison:
 What is the main alternative to compare with the intervention?
 Are you trying to decide between two drugs, a drug and no medication or
placebo, or two diagnostic tests?
 Your clinical question may not always have a specific comparison.
PICO
O= Outcome:
 What can you hope to accomplish, measure, improve or affect?
 What are you trying to do for the patient?
 Relieve or eliminate the symptoms?
 Reduce the number of adverse events?
 Improve function or test scores?
PICO
 Two additional elements of the well-built clinical question are the type of
question and the type of study. This information can be helpful in focusing the
question and determining the most appropriate type of evidence or study.
Type of Question
 The type of question is important and can help lead you to the best study design:
Most common type of questions: Type of study:
Diagnosis prospective, blind comparison to a gold standard or

how to select and interpret diagnostic tests cross-sectional
Therapy
how to select treatments that do more good than harm randomized controlled trial > cohort study
and that are worth the efforts and costs of using them
Prognosis
how to estimate the patient’s likely clinical course
over time (based on factors other than the cohort study > case control > case series
intervention) and anticipate likely complications of
disease
Etiology/harm
cohort > case control > case series
how to identify causes for disease
Type of Study
As you move up the Meta analysis

Meta analysis
pyramid the study
designs are more Systemic review
rigorous and allow for Systemic review
less bias or systematic Randomized control trial
error that may distract Randomized control trial
you from the truth.
Cohort studies
Cohort studies
Case control studies
Case control studies
Cases series/ case report
Cases series/ case report
Animal research
Animal research
Why should I use PICO?
• To help define problem in clarify it in your own mind
• To prepare for searching
• To ask patient centered questions.
• Developing the question requires:
– Some background knowledge of the condition
– Understanding of the patient and what are the outcomes and beliefs
that matter to this patient
• Death? Disability? Quality of life? Cost? Improvement of symptoms?
ExampleIntervenon Questions
• create a PICO and a focused clinical question for this case:
54 year old male patient was diagnosed with intermediate

grade prostate cancer and wants to know whether to get a
radical prostatectomy or radiation treatment. He is
concerned about death from prostate cancer and also risks of
impotence and incontinence.
Formulate the Clinical
QuestioPICO
P - 54 year old male with intermediate grade prostate cancer

I - radical prostatectomy
C- radiation treatment
O- reduce risk of mortality, impotence, and incontinence
 Focused clinical question

In 54 year old male patients with intermediate grade
prostate cancer is radical prostatectomy more effective
compared to radiation treatment in reducing the risk of
mortality, impotence, and incontinence?
EBP Step 1a:
Classify the type of the question
 What is the treatment?
Question of INTERVENTION
 What causes the problem?
Question of ETIOLOGY, RISK
 Does this person have the problem?
Question of DIAGNOSIS
 Who (and how likely) will get the problem?
Question of PROGNOSIS
Example
• The reverse of intervention questions-they deal with
harmful outcomes of an activity or exposure (public
health issues)
• Develop a clinical question for the case:
Seble is a smoker and just found out that she is 3
months pregnant. She quit smoking immediately. But
she is worried if her developing baby was harmed
and if the baby is at risk for having developmental
problems. She is asking you if smoking during the
first trimester can harm her baby?

Etiology or Risk Questions
• P-babies of mothers who smoke
I-smoking in first trimester
C-nothing
O-increase risk of developmental problems
• Question: Are babies of mothers who smoke during

their first trimester at an increased risk of
developmental disabilities?

Diagnosis
• These questions are concerned with how accurate a

diagnostic test is in various groups and in
comparison to other tests or usually to a “gold
standard test”.
As part of your clinic assessment of elderly patients,

there is a hearing check. You think that a simple
whispered voice test is very accurate compared to
other methods. You want to do a literature search.
What is your question?

Example
• P-elderly people
I-whispered voice test
C-no test (or other tests)
O-accurate diagnosis of hearing problems
• Question: In elderly people, does the whispered

voice compared to other tests give an accurate
diagnosis of hearing problems?

PICO formats
• For a therapy:
In _____(P), what is the effect of _____(I) on ____(O) compared with ____(C)?
• For etiology:
Are ____ (P) who have _______ (I) at ___ (Increased/decreased) risk for/of_______ (O) compared
with ______ (P) with/without ______ (C)?
• Diagnosis or diagnostic test:
Are (is) _________ (I) more accurate in diagnosing ________ (P) compared with ______ (C) for
_______ (O)?
• Prevention:
For ________ (P) does the use of ______ (I) reduce the future risk of ________ (O) compared
with _________ (C)?
• Prognosis:
Does __________ (I) influence ________ (O) in patients who have _______ (P)?

Access/ acquire Access
1. Start “hunting” from the best resource: Match your

question to the best medical information resource
for this question.
2. Searching for evidence that has already been

appraised for validity and reliability decreases the
amount of time needed to determine whether the
information is reliable
Hierarchy of Evidence- Access evidence at
the level that will give you the best evidence
Track Down
Filtered & Critically Appraised
Expert Opinion and Not Filtered
Background info.
Most clinically relevant (at the top) Least clinically relevant (at the bottom)
Why not get info only from textbooks and
review articles?
• Texts and review articles?
• Dated – perhaps by several years
• Often biased
• Author chooses article that he/she agrees with (or has written)
• Author chooses articles of his/her friends
• Author does not identify all the relevant literature
• Review’s methods are not explained
• These resources help with background knowledge (learn about disease)
not foreground (answer the specific clinical question for this patient)

Why not get info only from
guidelines?
They can assure standards of care but:
• Can be biased
• May not always be developed by experienced experts
• Are not always evidence-based
• Can work for most patients but not for all
• Can work in some circumstances but not in all
• Can be dated
• There may not be guidelines for everything

Databases Useful for Finding Individual
Research Reports
MEDLINE®

CINAHL

PsycINFO®

Databases Useful for Finding
Pre-Appraised Evidence

Cochrane Database of Systematic Reviews

BMJ Clinical Evidence

Database of Reviews of Effects (DARE)

National Guideline Clearinghouse (NGC)

Physician’s Information and Education Resources (PIER)

American College of Physicians Journal Club (ACP)
Filtered and Critically Appraised
Evidence-Based Resources
• The Cochrane Library by The Cochrane Collaboration via Wiley
• Independent non-for-profit international collaboration

• Reviews are among the studies of highest scientific evidence
• Minimum Bias: Evidence is included/excluded on the basis of explicit
quality criteria
• Reviews involve exhaustive searches for all RCT, both published and
unpublished, on a particular topic
• Abstracts searchable for free on the Internet; complete database is
available via HINARI for most countries

Benefits for using not-evaluated databases
for EBM research (PubMed, Cinahl)
 Create comprehensive search strategies
 Conduct systematic reviews of the literature
 Conduct synonym searching utilizing thesauri
 Set up and distribute alerts relating to
evidence-based medicine
 Limit to specific populations & publication
types
 Utilize EBM built-in filters (search strategies)
Licensed Databases Versus Web-
Based Search Engines
Licensed databases such as PubMed® list the journals indexed,

which allows users to know which journals they are searching

Internet search engines such as Google and Google Scholar
search the Internet, but there is no transparency as to what
information is included in the search
Internet search engines include the grey(ancient) literature,
which include unpublished drug trials, reports, or conference
proceedings. Because there is no peer review of this evidence,
it should be appraised to ensure that the information is reliable.
Combining a licensed database with an Internet search engine

may yield the best search results

Three Commonly Used Search
Strategies
Keyword searching uses words generated from each


component of the PICO question

All appropriate keywords, including common terms,

synonyms, acronyms, phrases, coined phrases, and brand

names, need to be used
Major strengths: Provides a quick snapshot of how helpful a

database will be in finding relevant evidence

Major weaknesses: May miss studies that do not exactly
match the authors’ keyword choices; may find many studies
irrelevant to the PICO question
Strategies cont.….
Subject headings searching uses a standardized set of

preselected terms for the search

Also referred to as controlled vocabulary, subject terms,
thesaurus, descriptors, or taxonomies
Major strengths: Searches can be broadened without

considering every synonym for the chosen keyword;

studies selected only if at least 25% relevant to the topic,
thus decreasing the number of irrelevant hits
Major weaknesses: Newly developed technologies,

phrases, and acronyms may not yet be linked in the

database and thus be missed
Strategies cont.….
Title searching uses keywords generated from the “P,” “I,”

and “O” components of the PICO question to search article
titles with the same keywords
As with the use of keyword searches, all appropriate

common terms, synonyms, acronyms, phrases, coined

phrases, and brand names need to be used
Major strengths: Increases the chance of the article found
being relevant to the PICO question and is highly effective in
finding relevant articles
Major weaknesses: Misses studies that do not contain the

keywords in the title

Combining Searches
Placing several concepts from the PICO question in one


search allows a simultaneous search, but it cannot be

determined which concept has the most available evidence
Running multiple single-word searches allows the number of

“hits” to be seen for each. Then decisions can be made to

possibly use Boolean operators.
Using the Boolean operator “AND” is useful when narrowing

a search to combine two search results. BOTH terms need to

be present or an article will not be included in the results.
Using “OR” will expand a search to include either one or both
terms in the results
Using “NOT” to exclude search

Combining Searches cont.…
Combining Searches cont.…
Using Limits in Searches
Using the “limit” function pares down a large results list


Options for limiting the results vary by database


Limiting to RCTs or meta-analysis first can help determine

the highest level of evidence that is available
Limiting the search may result in missing relevant evidence
(e.g., limiting the search to “full-text only” eliminates all
publications that the database does not subscribe to in full
text)
Using Reference Management
Software Systems (RMS) in Searches
Often referred to as citation managers
Used to save, search, sort, share, and
continuously add, delete, and organize

promising citations
Web-based proprietary example: Endnote®


Open-source options include


Mendeley (http://www.mendeley.com) and


Zotero (http://www.zotero.org)
Practical lesson
 PubMed
 HINARI
 Cochrane library
 Google scholar
Appraise Apprais
e
 EBP Step 3: Appraise:
Assesses
A. Validity
B. Reliability
C. Applicability
Critical appraisal checklist
1) What did the authors want to find out or prove?
2) Why?
3) Are they making any assumptions or basing their work on previous work or thought?
4) Summarise the methods used.
5) Can you see anything wrong with what they did?
6) Would you have done it differently?
7) What were their results (in detail)?
8) What is the significance of the results, in the opinion of the authors?

9) Do you agree?
10)Are there any claims that are not supported by the data?
11)Are there any questions left unanswered by this paper?
Do
12) you think this paper is relevant to Ethiopia?

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Evidence Based Practice

Adamu Takele (MPH)

 Information Science is an interdisciplinary science primarily

 This is information needed by those at the bottom of the

 Indicator based essential dataset Registers

 Data elements - std. definitions

 Format of tables, graphs & reports

Determine what data to collect

Must know – Should know –

•Apply Steps and processes of evidence based practice

02/13/2021 Adamu Takele (MPH) 18

 EBP is “the careful, clear and wise use of current best

Clinical expertise Patient

(Check all that apply)

A. Training, clinical experience and consultation with

B. Convincing evidence (non-experimental) from

C. Preferences of the patient

D. Active search of Randomized Controlled Trials,

A. Training, clinical experience and consultation

B. Convincing evidence (non-experimental) from

C. Preferences of the patient

D. Active search of Randomized Controlled Trials,

Institute of Public Health

A. Training, clinical experience and consultation with

B. Convincing evidence (non-experimental) from

C. Preferences of the patient

D. Active search of Randomized Controlled Trials,

A. Training, clinical experience and

B. Convincing evidence (non-experimental)

Institute of Public Health

Institute of Public Health

Institute of Public Health

Institute of Public Health

 It starts with the patient and ends with the

 The patient’s preferences MUST be

A. Training, clinical experience and consultation with other

B. Convincing evidence (non-experimental) from articles, case

C. Preferences of the patient

D. Active search of Randomized Controlled Trials, Systematic

Institute of Public Health

Don’t forget to allow for individual

If you checked all 4 items…

B. Convincing evidence (non-experimental) from articles,

C. Preferences of the patient

D. Active search of Randomized Controlled Trials,

A. Training, clinical experience and consultation

B. Convincing evidence (non-experimental) from

C. Preferences of the patient

D. Active search of Randomized Controlled Trials,

2. ACCESS: Track down the best Evidence

validity and usefulness

 PICO stands for

PICO is a way to organize a well built and answerable

 Background questions : concerns general knowledge

• Is focused and relevant

 Assess the patient:

02/13/2021 Institute of Public Health 44

I= Intervention, prognostic factor or exposure:

Diagnosis prospective, blind comparison to a gold standard or

As you move up the Meta analysis

54 year old male patient was diagnosed with intermediate

P - 54 year old male with intermediate grade prostate cancer

 Focused clinical question

02/13/2021 Institute of Public Health 57

EBP &HI Emergency medicine&CC Nursing

EBP &HI Emergency medicine&CC Nursing