Evidence-based clinical practice (EBCP) combines application of current best research evidence with clinical expertise and attention to patients' values and preferences. Based on a collaborative project between the Norwegian Knowledge Centre for the Health Services and Innlandet Hospital Trust we present examples of existing systems and tools for EBCP and a framework for implementation of EBCP in Norwegian hospitals.
- Health personnel can access an increasing number of information resources online. The resources noted below are among the best for conveniently providing current best research evidence and guidelines.
- The Norwegian Electronic Health Library ( www.helsebiblioteket.no ) is a web-portal for health personnel with free access to EBCP- textbooks, guidelines, databases and 3000 journals in full-text.
- The Knowledge Pyramid (6 S model) conceptualizes where and how to find pre-appraised research evidence and recommendations to inform decisions in clinical practice.
- The knowledge refinery McMaster PLUS identifies new, relevant and pre-appraised studies, available through a federated search in the Knowledge Pyramid or as evidence feeds (e-mail alerts).
- Four years of practical work with EBCP in a non-academic hospital trust suggests optimal implementation of EBCP will require a change in culture and organisational structure, increased competence, improved IT infrastructure and better information resources at the point of care.
- Increased competence in EBCP can be achieved through the website www.kunnskapsbasertpraksis.no , textbooks, workshops and customized library services in hospitals.
- Appropriate bottom-up initiatives from frontline clinicians and their local leaders, support from top leaders, strategic documents and allocation of resources budgets can all facilitate EBCP.
- Targeted and adequately powered national and regional efforts are needed to increase the uptake of EBCP in Norwegian hospitals.
Evidence-based clinical practice (EBCP) combines application of current best research evidence with clinical expertise and attention to patients' values and preferences. Although this approach to medicine is widely advocated, full implementation of EBCP faces formidable challenges. In 2005 the Norwegian Knowledge Centre for the Health Services received a request from the largest regional hospital trust in Norway to support the uptake of EBCP in their hospitals. The Norwegian Knowledge Centre for the Health Services developed the Hospital Trust project in collaboration with Sykehuset Innlandet, a local hospital trust with 9 non-academic hospitals and 41 units serving 400 000 inhabitants living in 2 rural counties in a region the size of Denmark. Based on experiences from a range of projects in our hospital trust, in this report we present examples of existing systems and tools for EBCP and propose a framework to increase the uptake of EBCP.
This project was, from 2006 to 2010, developed and administered by two physicians from Innlandet Hospital Trust with part-time positions in the Knowledge Centre. Based on an initial qualitative study of hospital employees, we developed projects and initiatives together with health personnel and leaders in the local hospital trust. Throughout a stepwise iterative process we acquired knowledge about and experience with a range of existing systems and tools for EBCP and developed a comprehensive framework for working with EBCP within four main domains: Competence, organizational issues, technological infrastructure and information resources for knowledge support.
Examples of systems and tools for EBCP
Health professionals should become familiar with systems and tools for knowledge support that facilitate access to evidence-based recommendations and research evidence. The Norwegian Electronic Health Library (www.helsebiblioteket.no) gives health professionals free access to 3000 journals in full-text, medical data bases (e.g., Cochrane systematic reviews), clinical practice guidelines and textbooks (e.g.,UpToDate). Clinicians need unhindered access to pre-appraised and applicable evidence at the point of care, preferably delivered as treatment recommendations in practice guidelines. The knowledge pyramid (6 S model) places information resources in a hierarchy in which the sources at the top levels (such as EBCP textbooks and guidelines) provide recommendations based on systematic reviews of research evidence, while sources further down in the hierarchy (such as systematic reviews and individual studies) requires assessment of quality of evidence. EBCP textbooks and guidelines face the challenging task of making recommendations by integrating best current evidence with patient preferences and other contextual factors such as cost and availability. Systems such as GRADE and AGREE provide structure and transparency in guideline development and are finding increased use. High quality systematic reviews constitute "the gold in the pyramid" and should form the basis for recommendations in EBCP guidelines. Individual studies are placed at the bottom of the pyramid because their results may be unrepresentative and because many are limited by high risk of bias.
The Knowledge refinery McMaster PLUS, available in Norway through the Health Library, identifies a small minority of new studies and systematic reviews considered to be valid, relevant and interesting to health professionals according to specific criteria. These studies are available through e-mail alerts or through a federated search engine that searches all levels of the pyramid simultaneously.
Experiences with implementing EBCP in a local hospital trust
We present our experiences, based on 4 years of practical work with EBCP in the Hospital Trust project, in a proposed framework with four main areas. The report includes a table summarizing our analysis of barriers, facilitators and needs as well as a suggested action-plan for health workers aiming to increase uptake of EBCP. Here we summarize some key points within the four main areas.
1) Competence in EBCP. Widespread teaching activities have revealed great enthusiasm but also a significant need for improved competence in EBCP among health professionals and decision-makers. A range of educational offerings such as the online course www.kunnskapsbasertpraksis.no, workshops, textbooks and work-files for integrated clinical learning provide opportunities for developing competence. To supplement increasingly well-developed services from librarians, recruitment of front-line clinicians who can be trained to provide education and support is needed. Innlandet Hospital Trust collaborates with University Colleges in educating nurses.
2) The organization of hospital trusts. The process of introducing EBCP in health institutions requires cultural and organizational change and systematic efforts over time. We present an overview of organizational actions taken in Innlandet Hospital Trust to facilitate implementation of EBCP. Actions include establishment of an interdisciplinary group of dedicated professionals ("enthusiasts") with leadership support, allocated budget resources and protected time to perform specific projects. Local initiatives with recruitment of "enthusiasts" supported by their department leaders seem to be necessary to bring about changes at the point of care.
3) Technological infrastructure. EBCP is currently difficult to imagine without unhindered Internet access. Clinicians spend several minutes to get online due to time-consuming log-on procedures on computer workstations. Other limitations are suboptimal web functionality for e-learning and in the electronic systems for presenting local guidelines and integrated care pathways. Our insights have resulted in a new Intranet and Internet strategy to solve key problems in Innlandet Hospital Trust. We present five deficiencies in the current technological infrastructure that should be resolved at the regional and national level. A rapid technological development and improved access to the information resources described above also provide opportunities. With mobile phones busy clinicians can quickly go online and search for evidence-based recommendations or pre-appraised evidence to answer their clinical questions.
4) Tools for knowledge support. Health professionals in Innlandet Hospital Trust have, through access to the Electronic Health Library, McMaster PLUS, the locally developed "Knowledge egg" and well developed local library-services, experienced substantial improvements in access to information resources on all levels of the knowledge pyramid. Many health professionals seem to prefer the abundance of local practice guidelines and protocols (> 6000 in Innlandet Hospital Trust). Our efforts to improve quality, availability and systems for updating such local guidelines constitute pioneering work with high demands for methodological expertise and personnel. The Norwegian Knowledge Centre for the Health Services now supports a national network of health professionals in hospitals, working together to develop EBCP protocols.
Our experiences suggest that we have a long way to go to optimally implement EBCP in specialist health care. We need to change our culture and working methods, increase competence in EBCP among clinicians and decision-makers, and ensure access to high quality information resources at the point of care. A thoroughly grounded, systematic and comprehensive initiative in the specialist health care system, well coordinated with efforts by the actors with responsibility for quality in health care, is essential to ensure that the conscientious use of best current evidence becomes a natural part of clinical practice in our hospitals.