Introduction to Healthcare and

Public Health in the US

The Evolution and Reform of
Healthcare in the US
Lecture a
This material (Comp1_Unit9a) was developed by Oregon Health & Science University, funded by the Department of Health and
Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000015.
The Evolution and Reform of
Healthcare in the US
Learning Objectives
2
Describe evidence-based medicine,
clinical practice guidelines, and quality
indicators in medicine (Lecture a, b, c)
Describe the patient-centered medical
home model (Lecture d)
Discuss the key issues driving healthcare
reform in the US (Lecture e)
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
The Evolution and Reform of Healthcare in the US
Lecture a
Evidence-Based Practice
(Sackett, 1996)
3
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
The Evolution and Reform of Healthcare in the US
Lecture a
Evidence-Based Practice (EBP) is "the
conscientious, explicit and judicious use of
current best evidence in making decisions about
the care of the individual patient.
EBP integrates ...individual clinical expertise
with the best available external clinical evidence
from systematic research.
Evidence-Based Practice
EBP is a method that helps clinicians
make sound decisions about patient care
EBP combines:
Clinician skills
Patient values
Evidence from research
4
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
The Evolution and Reform of Healthcare in the US
Lecture a
Evidence-Based Practice:
Practice Guidelines
5
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
The Evolution and Reform of Healthcare in the US
Lecture a
Practice guidelines are evidence-based
recommendations
In 1990, Institute of Medicine (IOM)
Committee advised the Public Health
Service on Clinical Practice Guidelines:
Practice guidelines are systematically developed
statements to assist practitioners and patients in
making decisions about appropriate healthcare
Evidence-Based Practice:
Clinical Decision Support (CDS)
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
The Evolution and Reform of Healthcare in the US
Lecture a
CDS is ...a clinical system, application or
process that helps health professionals
make clinical decisions
Clinical Decision Support Systems are
active knowledge systems which use two
or more items of patient data to generate
case-specific advice
Evidence-Based Practice:
Clinical Decision Support (CDS)
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Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
The Evolution and Reform of Healthcare in the US
Lecture a
Some functions of decision support
systems:
Administration
Management of complexity
Cost control
Decision support: Supporting clinical
reasoning, promoting use of best practices
Hierarchy Of Evidence
8
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
The Evolution and Reform of Healthcare in the US
Lecture a
Literature is ranked in a hierarchy
The higher up in the ladder of evidence, the
better the quality of the study
Why have a hierarchy?
Allows grading of studies
Allows comparison of methodologies
Provides a framework that can be used during the
development of systematic review protocols
One method of hierarchical ordering: classify
information according to effectiveness,
appropriateness and feasibility
Hierarchy of Study Designs
9.1 Chart: The Hierarchy of Study Designs
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Health IT Workforce Curriculum
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Introduction to Healthcare and Public Health in the US
The Evolution and Reform of Healthcare in the US
Lecture a
level design comment
I Randomized controlled trials
Equal probability of assignment of
subjects
II Cohort studies Defined by exposure to factor
III Case control studies Defined by outcome of interest
IV Case series Systematic observation without controls
V Expert opinion, physiologic studies Only as good as the expert
Some Terms Defined
10
Health IT Workforce Curriculum
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Introduction to Healthcare and Public Health in the US
The Evolution and Reform of Healthcare in the US
Lecture a
Bias: Inaccuracies that produce a false
pattern of differences
Blinding: Attempt to eliminate bias by
hiding the intervention
Validity: The extent to which a variable or
intervention measures what it is supposed
to measure
Systematic Reviews
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Health IT Workforce Curriculum
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Introduction to Healthcare and Public Health in the US
The Evolution and Reform of Healthcare in the US
Lecture a
Systematic review: Search of the medical
literature is conducted systematically using
specific methods
Meta-analysis: A systematic review which
uses quantitative methods to summarize the
results
Systematic reviews can be conducted
Via journal clubs
Via data mining
Example: Cochrane Collaboration
Systematic Reviews (Continued)
9.2 Chart: Oxford EBM Hierarchy
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Health IT Workforce Curriculum
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Introduction to Healthcare and Public Health in the US
The Evolution and Reform of Healthcare in the US
Lecture a
Oxford EBM Hierarchy
Ia Systematic review of RCTs
Ib Individual RCTs
IIa Systematic review of cohort studies
IIb Individual cohort studies
IIIa Systematic review of case control studies
IIIb Individual case control studies
IV Case series
V Expert opinion, etc.
PICO
13
Health IT Workforce Curriculum
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Introduction to Healthcare and Public Health in the US
The Evolution and Reform of Healthcare in the US
Lecture a
Questions that are asked during Evidence-
Based practice and research:
P = Patient
What are the characteristics of the
patient/population/problem?
I = Intervention
What is the intervention, prognostic factor or
exposure?
C = Comparison
What is the main alternative to compare with
the intervention?
O = Outcomes
What is the measurement or improvement?
The Evolution and Reform of
Healthcare in the US
Summary Lecture a

14
Definitions for EBP
Practice guidelines
Clinical decision support
Hierarchy of evidence
Systematic reviews

Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
The Evolution and Reform of Healthcare in the US
Lecture a
The Evolution and Reform of
Healthcare in the US
References Lecture a
References
Clinical Decision Support. (n.d.). Retrieved December 6, 2011, from HIMSS website:
http://www.himss.org/ASP/topics_FocusDynamic.asp?faid=313
Manchikanti, L., Singh, V., Helm II, S., Schultz, D. M., Datta, S., & Hirsch, J. (2009). Evidence-Based
Medicine - An Introduction to an Evidence-Based Approach to Interventional Techniques in the
Management of Chronic Spinal Pain. Pain Physician, 12(E1-E33), Retrieved from
http://www.painphysicianjournal.com/2009/july/2009;12;E1-E33.pdf
Sackett, D. L., Rosenberg, W. M., Muir Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996, January
13). Editorial - Evidence-Based medicine: what it is and what it isn't. BMJ, 312(71), Retrieved from
http://www.hsl.unc.edu/Services/Tutorials/EBM/whatis.htm
Schardt, C., & Mayer, J. (2010, July). The Well-Built Clinical Question. Retrieved December 6, 2011, from
University of North Carolina at Chapel Hill - Health Sciences Library, Tutorials website:
http://www.hsl.unc.edu/Services/Tutorials/EBM/Question.htm



Charts, Tables, Figures
9.1 Chart: The Hierarchy of Study Designs adapted from Oxford Center for Evidence-based Medicine -
Levels of Evidence . (2009, March). Retrieved December 6, 2011, from Center for Evidence Based
Medicine website: http://www.cebm.net/index.aspx?o=1025
9.2 Chart: Oxford Center for Evidence-based Medicine - Levels of Evidence . (2009, March). Retrieved
December 6, 2011, from Center for Evidence Based Medicine website:
http://www.cebm.net/index.aspx?o=1025


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Health IT Workforce Curriculum
Version 3.0/Spring 2012
Introduction to Healthcare and Public Health in the US
The Evolution and Reform of Healthcare in the US
Lecture a