Information mastery: a practical approach to evidence-based care

Katrina WK Tsang 曾慧琦, David C Slawson

HK Pract 2011;49-51

Health care professionals are constantly bombarded with a large amount of medical information from journal articles and reviews, continuing medical education conferences, advertisements, to pharmaceutical representatives. But most doctors have little formal training in assessing the clinical usefulness of the information from these sources. Busy clinicians do not have the time to critically appraise the articles from the bedside or desktop pile of journals that is stacked higher and higher each month. When needing to find answers to clinical questions, the first source which clinicians turn to is often their fellow colleagues, most likely because doing so takes the least amount of time and the least effort to get an answer. In all likelihood, their colleagues also may not have the time to read the important articles either. Many doctors base their decisions almost exclusively on information obtained from local experts, pharmaceutical representatives and what their patients specifically request.¹

Even when physicians have time to read research articles, they also need additional time to read the clinical epidemiology journals on how to critically appraise articles with the latest techniques. For example, the concept of allocation concealment has emerged over the last decade to be an important part of the randomisation process in controlled-trials. Allocation concealment ensures that treatment assignment of potential subjects is not known to the investigators before subjects are enrolled into the study. Inadequacies often lead to exaggerated estimates of treatment effect.^2,3 Allocation concealment is just one example of an important concept necessary to critically appraise articles adequately. Who knows what will be the next new important concept from clinical epidemiology that may alter the way medical researches are evaluated?

Given the time constraints that most clinicians have, it is reasonable for them not to be expected to know all that clinical epidemiologists do. It is not necessary to know all the statistical calculations or the details of each methodology or technique. Instead, busy clinicians can rely on other Editorial more effective and efficient ways of identifying medical information. Useful database systems can help clinicians locate relevant and valid medical evidence with the least amount of work.

The usefulness of medical information can be evaluated conceptually by using the "Usefulness Equation"^4,5, or Usefulness of information = (Relevance x Validity) / Work. Medical information should be relevant to everyday practice and to patients, it should be true and it should require little effort to obtain. Using relevance as the primary screening, before determining validity, can result in the minimum amount of unnecessary work.

Relevance is determined if (i) it addresses a patient-oriented outcome that patients would care about and the outcome could make them live longer or better, (ii) the intervention addresses a problem or problems common to one's practice and is feasible and (iii) if the information is valid, an immediate change in clinical practice would be necessary.

Validity is the degree of truth found in the study's conclusions. Those drawn from controlled studies are given greater credibility than those made from other less rigorous research. Validity should be critically assessed by a non-biased person or persons with up-to-date knowledge and skills in clinical epidemiology. Beware of accepting evidence at face value simply because it is published in a prestigious journal or recommended by a specialist. Different rating systems for evaluating the quality of evidence are available to indicate the validity of studies, including the "Strength Of Recommendation Taxonomy" (SORT) used by the journal, American Family Physician.⁶

If the evidence is patient-oriented and found to be valid, we should also ask whether the new information requires a change in clinical decision-making. If so, this information is "Patient-Oriented Evidence that Matters" (POEM). Once a POEM is identified, those that evaluate the diagnosis, treatment or prognosis of an illness commonly seen in one's practice should be given higher priority. These common POEMs have the largest potential for impacting patient-care and thus carry the greatest relevance.

The work or effort needed to find, evaluate and apply information depends on factors such as how much time it takes and how much money it would cost. Working too hard to establish the relevance or validity of evidence will lower its usefulness (e.g. critical appraisal). On the other hand, information that requires minimal effort to obtain may also have low validity or relevance (e.g. advertisements). The best sources of information should be highly relevant and valid that requires minimal effort to obtain.

"Information Mastery" is a new paradigm used for finding, evaluating and applying the best evidence to patient-care. Its goal is to help practising clinicians of all disciplines to determine the source of information with the highest usefulness score. By acknowledging how difficult and time consuming it is to find and assess the most relevant and valid information on our own gives us permission to delegate this task carefully and responsibly to others.

In this alternative model of evidence-based medicine, most physicians learn to be Masters of Information at Proficiency Level 1 where they can recognise and apply the highest quality information available in their daily care of patients. Practitioners are relieved of the expectation to read original articles. The work of critically appraising articles is instead delegated to a group of specifically trained clinicians within the specialty who are Level 2 users. These individuals regularly scan the literature pertinent to their discipline, determine the relevance and validity of new information, and make these new POEMs available for others in their respective fields. Level 3 providers are those who review the primary literature and publish systematic reviews and meta-analyses.

Currently, there are information systems such as BMJ Updates/ Clinical Evidence, Dynamed and Essential Evidence Plus, that are designed to alert physicians to new POEMs (a "foraging", "first alert" or "push" tool). These databases also allow clinicians to access information again at the point of patient-care through the internet or various handheld digital devices (a "hunting" or "pull" tool). Without any, clinicians will not reliably know when new information is available, nor easily find it during a busy clinical session when needed.

Being a "skilled user of medical information" allows clinicians to maximise the value of their services by paying attention to the cost and balancing it with the quality of their interventions as they relate to the patient, patient's family and the entire community. Information Mastery offers a way to empower clinicians to use the best possible information available at the point-of-care to help patients live longer and better. Maybe it is time to recycle the stack of journals that has been piling up beside your bed or on top of your desk and become an Information Master!