in a single organization—typically the local hospital—that provides an array of services from home health to outpatient to nursing home care, rural team members in many settings often have easier access to one another and closer communication as patients move across care sectors. When specialty or subspecialty care is involved, however, it is not uncommon for clinicians to be communicating with other providers located 50 or 100 miles away. Ensuring that all relevant information from the distant site accompanies the patient back to the rural community can be problematic, and open communication can be inhibited. Ensuring that team concepts and processes are employed under these circumstances may be more challenging.

Employ Evidence-Based Practice

Providing evidence-based care requires that clinicians be skilled in accessing the current knowledge base, including literature syntheses (e.g., Cochrane Collaboratives) and practice guidelines promulgated by professional organizations and other reputable sources (French, 1999; Grad et al., 2001; Rosswurm and Larrabee, 1999; Walshe and Rundall, 2001). This competency further requires that clinicians be able to integrate evidence with clinical expertise and patient values.

As the science base has grown and the complexity of care has increased, it is apparent that applying science appropriately to practice for every patient requires carefully designed care processes. Indeed, this competency relates directly to another of the ten simple rules alluded to above: that decision making is evidence-based, with clinicians providing care and administrators facilitating system redesign on the basis of scientific knowledge.

Prerequisite to this competency is having access to current evidence. Historically, this competency has been difficult to achieve for clinicians in many rural environments because of a lack of such access. Because they are often few in number, clinicians in rural areas can have difficulty obtaining coverage to attend regional or national educational conferences. Likewise, rural facilities have traditionally been beyond the scope of educational opportunities such as grand rounds and in-house presentations that are common to teaching hospitals and other entities.

The availability of the Internet and web-based information from such sources as the Agency for Healthcare Research and Quality now gives the rural workforce virtually the same opportunities as their urban counterparts to access the latest information and ensure that their patients will receive services based on the most current evidence available. However, the applica-



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