Evidence-Based Clinical Decision Making

The Professions in Society

Sources and Levels of Evidence
Reporting Evidence
Effects on the Clinical Process

Slide 3.1

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
 The Professions in Society
Define the core body of knowledge
(competencies)
1. Select who will study and be trained
2. Determine who will enter the profession
3. Establish a code of conduct
4. Discipline members
5. Structure of behavior and relationships
How will the professions change
in the information age? Slide 3.2

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
Professions and Organizations
 The market for their skills is global rather then
organizational. They have a global set of peers.
 Inherent conflict between requirements of the
profession and allegiance to the corporation.
 They obey a different set of rules and are
affected by a different set of influences.

Slide 3.3

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
 Historic Hippocratic Oath
I swear by Apollo Physician and Asclepios and Hygeia and
Panacea and all the gods and goddesses, making them my
witnesses, that I will fulfill according to my ability and
judgment this oath and this covenant:

To hold him who has taught me this art as equal to my parents

and to live my life in partnership with him, and if he is in need
of money to give him a share of mine, and to regard his
offspring as equal to my brothers in male lineage and to teach
them this art—if they desire to learn it.
Slide 3.4

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
 Historic Hippocratic Oath (cont.)

I will neither give a deadly drug to anybody who asked for

it, nor will I make a suggestion to this effect. Similarly I
will not give to a woman an abortive remedy. In purity and
holiness I will guard my life and my art.

I will not use the knife, not even on sufferers from stone,
but will withdraw in favor of such men as are engaged in
this work. (Guilds of Barbers-Surgeons)
Slide 3.5

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
 Doctor–Patient Relationship

Community

Family Patient Physician Profession

Slide 3.6

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
 Role of the Health Professions
How does a society value and delegate responsibility to the
professions? What might cause values and practices to
change?

Are the values, standards and conventions that serve as the

foundation for the medical profession universal?

Slide 3.7

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
When Was This Observation Made?
“It has become increasingly difficult to keep
abreast of and to assimilate the investigative
reports which accumulate day after day. . . .
[My colleague] was ill at ease because he felt
unable to control even the area of his own
discipline; one suffocates, he once told me,
through exposure to the massive body of
rapidly growing information.”
Slide 3.8

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
 Published in 1872

• Bernhard R. K. von
Langenbeck
(1818-1887)
German surgeon

Slide 3.9

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
 Flexner Report 1910
• Transformed the nature and process of medical education in
America

• Established the biomedical model and embraced scientific

knowledge, adopting a required basic science curriculum

• Elimination of proprietary and apprenticeship schools

• This model of medical education combining basic and clinical

sciences exists today

www.ncbi.nlm.nih.gov/pmc/articles/PMC3178858 / Slide 3.10

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
 The Third Pillar of Medical Sciences
Innovations in medicine occurring at the interface of engineering
Basic sciences Clinical sciences
Biochemistry General medicine
Anatomy Surgery
Physiology Dermatology
Pathology Pediatrics
Pharmacology Neurosciences
Psychiatry
Engineering sciences (Carle Illinois College of Medicine)
ER medical management systems (medical GPS)
Nano bubble delivering pro-drugs
Biophotonics
Optical coherence technology (OCT)
Molecular prosthesis (cystic fibrosis)
Bio materials Slide 3.11

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
Classic Hospital Functional Structure: Clinical and Administrative

Board of Trustees
Medical Joint Conference
Staff Committee
Administrator

Medical
Director Finance Administrator Administrator Clinical
Hospital Services Services
Personnel
Medicine
Surgery
Obstetrics Purchasing Food Nursing Labs Pharmacy
Radiology Services
Pediatrics
Pathology
Maintenance Admissions Medical Radiology
Anesthesia
Records

Housekeeping Slide 3.12

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
 Patient-Oriented Knowledge System
System structure Internet,
Scientific
Training social
evidence
ACO media
B
D

Community 1. EMR 2. EHR 3. HIE 5. Integrated

of • e-trials (1) decision support • e-trials (3) PHR
practice

F
A
E
Decision Knowledge
Experiential accumulation
4.
Networked HIE,
Outcome–decision health data vault
relationship Slide 3.13

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
Evidence-Informed Decision Making

Best available
Environment and
research evidence
organizational
context
Decision
making
Population
Resources,
characteristic,
practitioner
needs, values,
expertise
preferences

Slide 3.14

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
 Decision Science: Decision Types and Logic

Type Logic Based on

Evidence-based Descriptive Facts

Biological
Genomic Normative Judgment or expert
Engineering
reasoning

Intuitive Subconscious Holistic thought

Affective Emotion Values Slide 3.15

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
 Developing a Rapid Response Team
Knowledge capture from existing systems to inform clinical
processes?

Are these decisions based on facts or judgment, or both?

Sources of knowledge:
• Medical records
• Charge and ER nurses
• Respiratory therapist
• Attending doctors and hospitalists
• Networked medical centers
• Accreditation agencies
Slide 3.16
• Insurance/financing
Copyright © 2019 Foundation of the American
College of Healthcare Executives. Not for sale.
“Mechanistic” Decisions in Clinical Practice

Research evidence Environment

Human genome and
“tailored to patient” organizational
Precision context
medicine
Population
characteristic, Resources,
needs, practitioner
values, expertise
preferences

Slide 3.17

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
Factors Typically Not Included in EHR

Patient values and preferences—not routinely

considered in practice

• Schooling
• Religion
• Culture
• Alternative health practices
• Stressors
Slide 3.18

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
 Family and Social Information in EHRs

Promoted thinking and

• Highlighted some
discussion about
challenging life
contextual information
transitions
(e.g., immigration,
• Supported team-based
income sources,
care plans
legacy of family
• Organized data clearly
violence, housing
for continuity of care
arrangements)
Slide 3.19

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
Customer-Perceived Service Quality
Prior Experiences
expectations (=perceived
performance)

Match between
expectations and
experiences
(=disconfirmation)

Service
quality Slide 3.20

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
 Defining Palliative Care
1. Palliative care is specialized medical care for people living with serious
illness.

2. It focuses on providing relief from the symptoms and stress of serious illness.

3. The goal is to improve quality of life for both the patient and the family.

4. Palliative care is provided by a team of palliative care doctors, nurses, social

workers, and others who work together with a patient’s other doctors to
provide an extra layer of support.

5. It is appropriate at any age and at any stage in a serious illness and can be
provided along with curative treatment.
SOURCE: Center to Advance Palliative Care. https://www.capc.org/about/palliative-care/ Slide 3.21
(accessed April 11, 2017).

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.
Change in Role of the Health Professions
1. How has the EHR changed the decision-making process of
medical doctors? Nurses?
2. As the clinical process changes, is there a loss of professional
autonomy? Individual autonomy?
3. What are examples of decisions that represent each type of
decision context in exhibit 3.1?
4. What changes in the selection, training, and reward of medical
professionals would you suggest given the changing role of the
society and information technology?
Slide 3.22

Copyright © 2019 Foundation of the American

College of Healthcare Executives. Not for sale.