6
Healthcare Professionals

Coordinator


Rae-Ellen W. Kavey, National Heart, Lung, and Blood Institute


Other Contributors


Frank Ascione, University of Michigan; Lisa Bero, University of California, San Francisco; Linda Burns-Bolton, U.S. Department of Veterans Affairs; Barry Carter, University of Iowa; Gray Ellrodt, University of Massachusetts; Pat Ford-Roegner, American Academy of Nursing; Arthur Garson, Jr., University of Virginia; Ada Sue Hinshaw, University of Michigan; Cato T. Laurencin, University of Virginia; Rona F. Levin, Pace University; Daniel Malone, University of Arizona; Bernadette Melnyk, Arizona State University; Nancy H. Nielsen, American Medical Association; Kimberly Rask, Emory University; Jon Schommer, University of Minnesota; Glen Schumock, University of Illinois at Chicago; Cary Sennett, American Board of Internal Medicine; Lee Vermeulen, University of Wisconsin; Lynda Welage, University of Michigan

SECTOR OVERVIEW

Evidence-based practice (EBP) has been defined as “the integration of individual clinical expertise and patient preferences and values with the best available external clinical evidence from systematic research” (Sackett et al., 2000). Although healthcare professionals may believe that this is how they have always practiced, performance assessments indicate that this is not the case (McGlynn et al., 2003). A growing literature recommends the use of evidence-based management practices, but such recommendations are not consistently implemented. The behavior of healthcare professionals represents the critical juncture between the theory of evidence-based medicine (EBM) and actual EBP. Effective mechanisms that link knowledge development to the diffusion and adoption of that knowledge will be essential to promoting the use of EBM in clinical decision making.



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6 Healthcare Professionals Coordinator Rae-Ellen W. Kavey, National Heart, Lung, and Blood Institute Other Contributors Frank Ascione, University of Michigan; Lisa Bero, University of California, San Francisco; Linda Burns-Bolton, U.S. Department of Veterans Affairs; Barry Carter, University of Iowa; Gray Ellrodt, University of Massachusetts; Pat Ford-Roegner, American Academy of Nursing; Arthur Garson, Jr., University of Virginia; Ada Sue Hinshaw, University of Michigan; Cato T. Laurencin, University of Virginia; Rona F. Levin, Pace University; Daniel Malone, University of Arizona; Bernadette Melnyk, Arizona State University; Nancy H. Nielsen, American Medical Association; Kimberly Rask, Emory University; Jon Schommer, University of Minnesota; Glen Schumock, University of Illinois at Chicago; Cary Sennett, American Board of Internal Medicine; Lee Vermeulen, University of Wisconsin; Lynda Welage, University of Michigan SECTOR OVERVIEW Evidence-based practice (EBP) has been defined as “the integration of individual clinical expertise and patient preferences and values with the best available external clinical evidence from systematic research” (Sackett et al., 2000). Although healthcare professionals may believe that this is how they have always practiced, performance assessments indicate that this is not the case (McGlynn et al., 2003). A growing literature recommends the use of evidence-based management practices, but such recommendations are not consistently implemented. The behavior of healthcare professionals repre- sents the critical juncture between the theory of evidence-based medicine (EBM) and actual EBP. Effective mechanisms that link knowledge develop- ment to the diffusion and adoption of that knowledge will be essential to promoting the use of EBM in clinical decision making. 

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 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE In 2003, the Institute of Medicine (IOM) Committee on the Health Professions Education Summit developed a new vision for clinical education in the healthcare professions. The overarching goal is that “all health pro- fessionals will be educated to deliver patient-centric care as members of an interdisciplinary team, emphasizing EBP, quality improvement approaches, and informatics” (Institute of Medicine, 2003). The goal of this health professional sectoral strategy process is to support that vision, as it applies specifically to increasing use of EBM in clinical practice. The focus is on the delineation of strategies that will shift healthcare delivery away from the traditional physician-dominated practice and toward a concept of practice performed by interdisciplinary teams empowered to seek out and imple- ment the best evidence for patient care. Such teams will have both the abil- ity and expectation to continuously learn and change, through informed access to evidence-based clinical decision support, informatics, and clinical data repositories. The potential scope of the sector includes all healthcare professionals. A minimal list would include physicians, nurses, nurse practitioners, physician’s assistants, pharmacists, social workers, dietitians, physical and occupational therapists, and medical technologists. This discussion uses physicians, nurses, and pharmacists as representatives of the healthcare pro- fessional sector; but the concepts articulated here are intended for potential application to all healthcare professionals. The remainder of this chapter describes the current state of EBP, identifies key activity categories, and proposes potential transformative initiatives for each of these three types of healthcare professionals. Physicians The vision of physicians as members of teams in which each participant is empowered to seek out the best evidence for care is a new and powerful image. Achieving this vision will require profound change, but evidence- based health care will not occur without that change. Effective mechanisms that link knowledge development to the diffusion and adoption of that knowledge will be critical components in promoting the active use of EBM in clinical care. The broader dissemination of technologies that support the delivery of evidence-based care will clearly be essential; but the information collected for this report—summarized in the paragraphs below—suggests that the main issue here is not only technical but also cultural: commitment to the principles of evidence-based, team-directed, patient-centered care will require a fundamental change in what physicians understand to be their primary obligations as healthcare professionals. That change in culture and professional norms—from an emphasis on the physician as the knowledge expert to an emphasis on the physician as a team member whose role is

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9 HEALTHCARE PROFESSIONALS to access and interpret relevant, timely, and appropriate information for delivery to the patient in conjunction with all members of the healthcare team—will drive the acquisition of the tools required to implement a vision of evidence-based care. The primary construct of patient-centric care—that patients themselves are central to the process and are actively engaged in self-education and management—is one that necessitates a major shift in how physicians are trained and how they practice. Without such changes in culture and profes- sional norms, physicians will fail to capitalize on opportunities to acquire and deploy the knowledge and technologies essential to achieving that vision of patient-centric care. The implementation of any process requires an assessment of the exist- ing state of the field. The current practicing physician population in the United States includes just less than 600,000 individuals; 86 percent of physicians are primarily involved in clinical practice, with 50 percent in practices with four colleagues or fewer, and of that 50 percent, 20 per- cent are in solo practice (American College of Physicians, 2005). Active practitioners range from those who have just completed training to those whose formal education occurred as long as 40 years ago. Actualization of the concepts of both EBM and practice quality assessment is also closely linked to access to information technology (IT). The rate of use of IT sup- port systems, from handheld computers to completely electronic medical record (EMR) systems, is continuously increasing in medical practice; but less than 25 percent of physicians currently use some kind of EMR and 40 percent use a handheld computing device to support their practice (Gans et al., 2005; Garritty and El Emam, 2006; Jha et al., 2006). Of note, the rate of EMR adoption is the lowest among physicians in smaller practices. In addition, training in EBP is also a relatively new concept, with the time dedicated to training in EBM varying with the specialty and the training program (Green, 2000). With such diverse ranges of individuals, baseline knowledge, technical support systems, and practice settings, any recom- mendations for change must be broad, flexible, and incremental. What is less well known but what can perhaps be inferred from data on behavior is how physicians perceive the technologies that are relevant to the implementation of EBM, that is, whether they perceive them to be important to their efforts to improve patient care. Clearly, one must be concerned that the slow adoption of healthcare IT—and the push back that has been apparent among leaders in the healthcare professions regarding efforts to promote quality measurement and industrial approaches to qual- ity improvement based on that measurement—reflects a prevalent attitude that the adoption of healthcare IT is not necessarily in the best interests of patient care (Audet et al., 2005). The shift to electronically based practice is expensive, particularly in a solo or small group practice setting. The

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20 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE implementation of many IT practices can require major changes in clini- cal processes that can slow the delivery of care, especially during the early stages of their adoption. Promoting the use of technologies believed to be fundamental to the implementation of evidence-based care will have to address these issues to overcome practitioner resistance. Again, the most important set of activities in which the healthcare professional sector may have to engage may be related to changing that attitude. Medical School Education The process of integrating EBM into medical school education is already well under way. In 1999, the American Association of Medical Colleges identified the concepts of EBM as a critical objective for medical education (Medical School Objective Project Writing Group, 1999). As an intrinsic part of medical education, training in EBM provides individual physicians with critical search and appraisal skills for review of the medi- cal literature, introduces the concept of continuous quality assessment as a routine of medical practice, and provides the basis for effective lifelong learning directly linked to patient care. Adoption of evidence-based recom- mendations optimizes the diagnosis and management of clinical conditions for which an evidence-based approach has been developed. One aspect of EBM that should make its adoption easier for current medical students is their nearly universal facility with IT as a routine part of daily life; maxi- mizing this advantage should be considered in the development of changes in the medical school curriculum. From these precepts, medical school edu- cators have introduced EBM into the medical school curriculum in a variety of ways. For example, innovative courses have transformed basic classes in epidemiology and statistics into intensely participatory discussions of cases designed to illustrate the principles of population health (Marantz et al., 2003). Preventive medicine has been integrated into clinical clerkships, and evidence-based decision making has become relatively standard during internal medicine rotations (Carey, 2000; Green, 2000). Evidence of the increased knowledge and use of EBM concepts in the first 3 years after medical school graduation is beginning to be reported; but as yet, there are few, if any, reports evaluating the use of EBM in posttraining clinical practice (Davidson et al., 2004; Dorsch et al., 2006). Finally, assessment of medical students’ knowledge of population health and evidence-based decision making needs to be a requirement for medi- cal school graduation. A review of content outlines and sample questions from the National Board of Medical Examiners published in 2003 indicates no formal content of this kind (National Board of Medical Examiners, 2003).

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2 HEALTHCARE PROFESSIONALS Graduate Training Beginning in 1999, the Accreditation Council for Graduate Medi- cal Education (ACGME) Outcomes Project redesigned the curriculum for residency and fellowship training after graduation from medical school to focus on the outcomes of the training rather than program process measures (ACGME, 1999). The project defined six basic core competen- cies: medical knowledge, patient care, systems-based practice, professional- ism, interpersonal/communication skills, and practice-based learning and improvement. Achievement of the last competency explicitly requires expo- sure to “investigation and evaluation of patient care practices, appraisal and assimilation of scientific evidence, and continuous improvement of patient care practices.” There is a timeline for implementation of this new approach to resident education: at this time, all residency training programs must have begun to provide learning opportunities in the six defined com- petency domains, with the requirement for full integration of the training in the competencies and their assessment by June 2011 (ACGME, 1999). The ACGME standards set a critical goal to provide residents with a practical working knowledge of EBP during their residency training that will allow them to provide optimal patient care on the basis of the best available evidence. Reports of early approaches to meeting the ACGME standards provide models of how evidence-based theory and EBP can be integrated into residency training; these approaches include exposures in multiple dis- ciplines (Bradt and Moyer, 2003; Rucker and Morrison, 2000). Ross and Verdieck (2003) have validated that this kind of educational exposure increases residents’ knowledge of EBM and their use of EBM principles in practice during their residency training. Proof that this kind of training will be sustained into postresidency practice is not yet available, nor is evidence that such training will improve patient outcomes. Education of Practicing Physicians The challenge of increasing the practice of EBM among physicians in practice is formidable. Physicians represent a diverse group of individuals, not least because of the wide range of time from the completion of medical training to the present. For example, 18 percent of practicing physicians are between 55 and 64 years of age and completed medical school an average of 30 to 40 years ago (U.S. Department of Health and Human Services, 2003). Not surprisingly, the time that a physician has been out of residency training has been shown to correlate with a lower rate of adherence to evidence-based management and the greater use of tests and therapies with no proven benefit (Conway et al., 2006). Despite continuing medical edu- cation (CME), there will be many for whom the formal concept of EBM is

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22 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE completely unknown. Nonetheless, winning the minds and hearts of prac- ticing physicians will be essential in achieving universal EBP. One potential mechanism for achieving this is CME, the standard approach to continuous learning for healthcare professionals. Currently, physicians are required to accrue a defined number of CME credits annually to maintain hospital priv- ileges, qualify for relicensure, or maintain specialty certification. However, despite the clear demonstration that the pure dissemination of information has a limited impact on behavior change among physicians, traditional lecture formats persist as the most common form of CME. Randomized controlled trials of educational interventions have shown that for physi- cians automated reminders, patient-mediated interventions, outreach visits, and the use of opinion leaders are more effective behavior change strategies than CME. Training on quality assessment in practice based on EBM-based quality assessment with pre- and posttraining practice audits has also been used effectively to increase knowledge and the rate of implementation of EBM (Dexter et al., 2001; Hunt et al., 1998; Kuperman et al., 1996). With this uneven landscape as the starting point, flexible innovative approaches to increasing evidence-based clinical practice will be essential. Although current medical school students and trainees have high levels of access to and comfort with computers and IT, these levels are highly variable among all medical practitioners (Gans et al., 2005; Garritty and El Emam, 2006; Jha et al., 2006). To remain up-to-date with recent evidence for optimal care, physicians need easy and immediate access to Internet- based knowledge repositories. A variety of computer-based clinical decision support systems have been shown to improve clinician performance and patient outcomes (Hunt et al., 1998; Kuperman et al., 1996) and to spe- cifically increase the rate of use of evidence-based guidelines (Dexter et al., 2001). However, physicians currently have limited access to such systems, and the initial investment and the technological support necessary to estab- lish and maintain them are substantial (Maviglia et al., 2003). Even with adoption of EMR systems, there is wide variation in the technical capabilities of these systems, with only 65 percent of the systems providing immediate access to clinical guidelines and protocols, and most of these have limited decision support capabilities. In addition, many of these systems do not include the essential ability to interrogate patient records for quality assessment and research (Gans et al., 2005). Although the use of such systems may eventually become universal and the functional capacities of physicians are likely to improve, the transition to EMR alone does not increase the rate of use of EBP. It does, however, provide the critical infrastructure needed to facilitate EBP. Given the finan- cial limitations inherent in small practice settings and the dominance of this mode of practice, external support will be needed to facilitate IT-supported practice for the majority of healthcare professionals. Therefore, at a mini-

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2 HEALTHCARE PROFESSIONALS mum, proposals to increase the rate of adoption of EBP must address both computerized and noncomputerized practice settings. Finally, regulatory oversight for practicing physicians needs to be expanded to include standards of EBM practice, quality assessment and improvement, and continuous learning, which should be mandatory for maintenance of certification. This oversight is beginning to occur, especially in internal medicine, in which the American Board of Internal Medicine has developed evidence-based clinical performance measures for physi- cians (LaBresh et al., 2004). There are several different practice assessment options, each of which includes a World Wide Web–based self-evaluation as well as some form of formal practice assessment; successful completion of an assessment results in credits for both the maintenance of certification and CME. Nurses Nursing is the largest of the healthcare professions, with nearly 3 million nurses in the United States, the majority of whom are practicing in hospital settings (U.S. Department of Labor, 2006). Registered nurses (RNs) are educated at various levels and receive associate degrees, hospital program- based diplomas, and baccalaureate degrees. Advanced-practice nurses (e.g., nurse practitioners and clinical nurse specialists) are educated through master’s degree and clinical doctoral programs, whereas nurse researchers are educated in doctor of philosophy and nursing science doctoral programs that place an emphasis on the learning of the knowledge and skills required to conduct rigorous studies that extend science and produce evidence to guide best clinical practices. Nurses assume vital roles in the healthcare system, such as (1) provid- ing high-quality direct patient care across the care continuum; (2) assessing and monitoring patients’ health status and outcomes; (3) planning, tailor- ing, implementing, and evaluating clinical interventions; (4) facilitating self-management strategies so that individuals achieve the highest level of health and adhere to prescribed treatments; and (5) promoting physical and mental health through patient education and anticipatory guidance. In addition, nurses are clinical researchers/scientists who lead interdisciplinary research teams in generating new knowledge and evidence to guide best clinical practices. They are also healthcare leaders and administrators who spearhead organizational change and systems improvements and teachers and mentors who prepare the next generation of direct care providers, educators, and nurse scientists. Although federal agencies, professional organizations, healthcare leaders, and insurers have emphasized EBP as a key strategy for improving the quality of health care and patient outcomes, the majority of nurses do

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2 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE not deliver evidence-based care (Institute of Medicine, 2003; Melnyk et al., 2005). A recent descriptive survey with a random sample of 1,097 randomly selected RNs from across the United States found that (1) almost half were not familiar with the term “evidence-based practice”; (2) more than half reported that they did not believe that their colleagues use research find- ings in practice; (3) only 27 percent of the survey participants had been taught how to use electronic databases; and (4) most reported that they did not search information databases (e.g., Medline and Cumulative Index to Nursing and Allied Health Literature [CINAHL]) to gather practice infor- mation, and those who did search these resources did not believe that they had adequate search skills (Pravikoff et al., 2005). Numerous studies have identified major barriers to the use of EBP, including (1) inadequate education and knowledge in EBP, including IT; (2) weak beliefs about the value of EBP; (3) negative attitudes toward research; (4) misperceptions about EBP (e.g., a perceived lack of time to implement EBP); (5) a non-EBP culture in healthcare settings and few resources at the point of care, including appropriate tools and a formal structure; (6) competing priorities; (7) a lack of administrative support and incentives to change practice; (8) insufficient numbers of advanced-practice nurses to serve as EBP mentors to direct care staff; (9) various levels of educational preparation; and (10) the omission of EBP as a responsibility and a lack of accountability in clinical practice (Fineout-Overholt et al., 2005; Melnyk and Fineout-Overholt, 2005; Pagoto et al., 2007). Recent anecdotal reports indicate that when nurses and healthcare pro- fessionals implement EBP, they feel more empowered and more satisfied in their roles as healthcare providers (Maljanian et al., 2002; Strout, 2005). These are important findings, because the nursing profession is facing the most severe personnel shortage in its history, with the current vacancy rate for RNs reported to be 8.5 percent (American Hospital Association, 2006). The demands on nurses as a result of this shortage have led to increasing reports of job dissatisfaction and an intent to leave the profession (Bowles and Candela, 2005). In a recent study, 23 percent of nurses intended to leave the profession, with another 37 percent uncertain of their future (Larrabee et al., 2003). Another recent report noted that the national average turnover rate for new nursing graduates is 35 to 60 percent (Zucker et al., 2006). High turnover rates are costly to the healthcare system and negatively affect patient outcomes (Aiken et al., 2003). Furthermore, an IOM paper, Keeping Patient’s Safe: Transforming the Work Environment of Nurses, stressed the importance of the simultaneous use of EBPs and the removal of the inef- ficient work of nurses as key strategies to obtaining a safe and satisfying practice environment (Institute of Medicine, 2004). Thus, in addition to improving the quality of care and patient outcomes, EBP may be a key factor in increasing job satisfaction and reducing nurse turnover rates.

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2 HEALTHCARE PROFESSIONALS Although RNs receive their foundational preparation through a variety of educational mechanisms (i.e., associate degrees, hospital program-based diplomas, and baccalaureate degrees), all educational programs need to cul- tivate a spirit of inquiry in their students and prepare them to be clinicians who practice EBM, appropriately leveling EBP-related knowledge, skills, and competencies on the basis of the level of educational preparation. A meta-analysis conducted in the late 1980s indicated that nursing interven- tions based on scientific evidence rather than steeped in tradition achieved better patient outcomes (Heater et al., 1988). Despite the findings from that meta-analysis, academic programs in nursing have been slow to incorporate the teaching of EBP. Nursing education at both the baccalaureate and the master’s levels has historically focused on preparing graduates to be the generators of research instead of the users of evidence who can efficiently translate research findings into practice to improve care, even though the American Association of Colleges of Nursing contends that nursing educa- tion is to prepare students to “use scientific knowledge in their practice” (American Association of Colleges of Nursing, 2004). Research in nursing academic programs has also traditionally been taught in isolation and not as part of other nursing courses, and thus, students have failed to see the application of research findings to clinical practice (Burke et al., 2005). The tedious nature of the methods used to teach research and a lack of relevancy to real-time clinical situations have contributed to the pervasive negative attitudes toward research by practic- ing nurses and misperceptions that EBP is not feasible because of today’s healthcare environment and nursing shortage. To prepare nursing graduates to be evidence-based clinicians, nursing school faculty must have the in-depth knowledge and skills needed to teach and model EBP. In a recent descriptive survey of 79 nurse practitioner edu- cators from the National Organization of Nurse Practitioner Faculties and the Association of Faculties of Pediatric Nurse Practitioners, participants’ self-reported knowledge of EBP was high and they believed in the benefits of EBP as well as the need to integrate it into academic curriculums. How- ever, the faculty responses on the survey indicated a knowledge gap in EBP teaching strategies. Furthermore, few of the faculty’s academic programs offered a foundational course in EBP. Additional findings from that study indicated significant relationships among educators’ knowledge of EBP and (1) their beliefs that EBP improves clinical care, (2) their beliefs that teaching EBP will advance the profession, (3) how comfortable they feel in teaching EBP, and (4) whether clinical competencies in EBP are incorpo- rated into clinical specialty courses (Melnyk and Fineout-Overholt, 2008). Therefore, there is a tremendous need to equip academic faculty with in- depth knowledge and skills in EBP so that they can teach and model it for their students. A recent position statement from the National League for

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2 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE Nursing (NLN) calls for new models of nursing education that will address demands for competencies in EBP. In that statement, the NLN reports that the “wide-scale transformation of education continues to be slow to mate- rialize” (National League for Nursing, 2007). Finally, the findings from a recent systematic review indicated that stand-alone classroom teaching of EBP or critical appraisal courses improved students’ knowledge of EBP but that only clinically integrated teaching improved their EBP-related skills, attitudes, and behaviors. Therefore, the consistent integration of EBP in the curriculum and skills building in EBP through an interdisciplinary approach to learning, including healthcare IT, throughout educational programs are necessary to prepare clinicians who will deliver evidence-based care upon entry into practice and throughout their careers (Coomarasamy and Khan, 2004). In the current healthcare climate, nurses are challenged with heavy patient caseloads and understaffing in nearly all types of healthcare systems, including acute-care hospitals, home health care, primary care, correctional facilities, and long-term care settings. The typical profile for a practicing nurse as well as a faculty member in the new millennium is a 47-year-old individual who has not been educated in EBP or healthcare IT as part of his or her basic nursing curriculum (U.S. Department of Health and Human Services, 2004). These factors create substantial challenges for the rapid advancement of EBP in the nursing profession. Additionally, continuing education for nurses is not mandated in many states. In those states in which continuing education is required for relicensure, it is typically less than 25 contact hours every 2 years. Therefore, rigorous initiatives are necessary to transform and sustain an evidence-based approach to clinical care, including education in and access to healthcare IT, tools that enhance EBP, and a culture that supports this type of practice. Even if healthcare providers are educated in and have the skills needed to implement EBP, without a culture that supports and provides the necessary resources for this type of practice, it is unlikely that EBP will be sustained. Leaders within healthcare organizations (e.g., chief medical and nursing officers), with the input of interdisciplinary healthcare professionals, need to create an exciting vision and strategic plan for EBP, as well as provide the culture and necessary resources to support it (Melnyk and Fineout- Overholt, 2005). The strategic plan must then be clearly communicated to all interdisciplinary healthcare professionals. Expectations for EBP should be set and integrated throughout the healthcare system’s philosophy and performance standards, with staff having accountability and incentives for meeting those standards. Findings from previous studies have indicated that there are a num- ber of facilitators of EBP in healthcare systems, including (1) healthcare providers’ knowledge and skills in EBP, (2) healthcare providers’ beliefs that

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2 HEALTHCARE PROFESSIONALS EBP improves care and patient outcomes, (3) healthcare providers’ beliefs in their ability to implement EBP, (4) EBP mentors who are skilled in EBP and organizational change, (5) administrative/organizational support, and (6) journal clubs and EBP fellowship programs (Fineout-Overholt et al., 2005a,b; Levin et al., 2007; Melnyk and Fineout-Overholt, 2005; Pagoto et al., 2007). Evidence from a recent survey also indicates that healthcare professionals who rate themselves higher on knowledge and beliefs about EBP are more likely to teach it to others (Melnyk et al., 2003). Therefore, to advance EBP, healthcare systems should implement educational and fellowship programs to enhance the EBP-related knowledge, beliefs, and skills of its staff; provide EBP mentors who can work directly with staff to implement EBP initiatives, such as journal clubs and EBP implementation/ outcomes management projects; and provide the necessary administrative support and resources, including computers for the use of EBP at the point of care and healthcare IT systems that are user friendly. Several conceptual models can guide the implementation of EBP in healthcare systems. Some models provide process frameworks for the imple- mentation of EBP by individual practitioners. These include (1) the model of Stetler (2001), (2) the EBP model of DiCenso and colleagues (2005), and (3) the Clinical Scholar Model (Schultz, 2005). Other models are focused on the systemwide implementation of EBP, including (1) the Iowa Model (Titler, 2002), (2) the model of Rosswurm and Larabee (1999), and (3) the model of advancing research and clinical practice through close collabo- ration (Fineout-Overholt et al., 2005a,b; Melnyk and Fineout-Overholt, 2002). However, evidence has yet to be generated in the form of model testing or full-scale randomized clinical trials to support the majority of these models. Thus, studies of this nature are greatly needed. Outcomes management is another key substantive area within EBP. The measurement of outcomes related to practice changes based on evidence is the final step of EBP and provides empirical support for the impacts that these changes have on patient outcomes and healthcare systems. The mea- surement of outcomes is key to influencing healthcare policy and facilitating the widespread adoption of best practices across healthcare systems. Pharmacists Historically, the pharmacist’s role focused on the preparation, formula- tion, and distribution of drug products to the public. As drug formulations became more standardized and the manufacture of drug products gradu- ally became the responsibility of the pharmaceutical industry, the role of the pharmacist shifted more to the safe distribution of the drug product, ensuring that the patient received the right drug in a timely manner. Over the years, the pharmacy profession has continued to evolve to one that is

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 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE TABLE 6-1 Sample Initiatives Already in Place Competency Initiative Roles Model Practice Interoperable MD, RN, The Veterans Health Administration support technology NP, LPN, provides care for 5.3 million patients at to support Pharm.D. 1,400 care sites and provides systemwide implementation access to EMR. To increase adherence of EBP to evidence-based guidelines for decision making, performance profiles based on EBM-defined risk markers were created for all care providers. Self-comparisons of performance resulted in serial improvement in all markers of diabetes care (Kupersmith et al., 2007). Continuous Web-based MD, RN, The American Heart Association created learning training NP, LPN, Get with the Guidelines program to and practice included with Pharm.D. increase the rates of physician adherence support roll-out of to secondary prevention guidelines after evidence-based myocardial infarction. Physicians use a guidelines web-based management tool for data collection and online feedback. Twenty- four hospitals collaborated in a pilot study; after 12 months, clinically and statistically significant increases in the use of four of seven measures from the baseline were demonstrated, with a high rate of baseline use maintained for the other measures (LaBresh et al., 2004). Online distance MD, RN, The Center for the Advancement of education and NP, LPN, EBP at Arizona State University offers immersion Pharm.D. a 17-credit online distance education workshops graduate/post-master’s degree certificate in EBP plus week-long EBP multidisciplinary immersion workshops for healthcare professionals. CME and Inclusion of MD The American Board of Internal Medicine regulatory physician- Physician Consortium for Performance oversight specific EBM Improvement has developed three different training and practice assessment options. Each includes reporting for a web-based self-evaluation as well as maintenance of some form of formal practice assessment. certification Successful completion results in credits for both maintenance of certification and CME (American Board of Internal Medicine, 2007). NOTE: LPN = licensed practical nurse; NP = nurse practitioner.

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9 HEALTHCARE PROFESSIONALS centers, and practices as a way to jump-start their adoption by healthcare professionals. Establish healthcare cultures that support the systemwide imple- • mentation and the sustainability of EBP, including resources at the point of care, EBP mentors, and time for healthcare professionals to engage in EBP as routine. Support the development and implementation of a common vocabu- • lary and interoperable technology to optimize the use of patient data both in practice and for assessment of evidence-based guideline implementation, and provide feedback to healthcare professionals. Recommend the provision of EBM guidelines in an IT format • compatible with all forms of EMR as well as in paper versions for healthcare professionals who do not yet routinely use electronic technologies. Work with professional practice organizations to develop guideline • implementation packages, including clinical practice and patient education tools, to be released with all major guidelines. Support the provision of add-on modules (electronic and paper • based) to efficiently update existing evidence frameworks. Support the study of regionalized processes for the provision of IT • support to small practices, such as collaborative practice models, virtual large group practices, public health-based support, or region- alization through interaction with academic medical centers. Involve healthcare professionals in the design and development of • IT support systems to reduce redundant data entry, screen changes, and forced recommendation practices. This will serve the dual role of making such systems directly responsive to the needs of practic- ing healthcare professionals and of creating leaders who will advo- cate for EBM and IT-supported care in their home communities. Proposed Initiatives in Use of Medical Evidence Generation as Standard Care Educate healthcare professionals about how existing information • from patient care can be used as clinical research data. Increase opportunities to participate in practice-based research to • expose healthcare professionals to the means of generating the science base from which evidence-based recommendations are developed. - Involve practicing healthcare professionals in the development of research questions with direct clinical practice. - Provide specific opportunities for solo and small group prac- tice and community hospital settings to participate in clinical practice research networks.

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0 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE Support formal evaluations of the impact of EBP on clinical • outcomes. Seek mechanisms for financial support of participation in registries • and research databases, for example, the American College of Sur- geons National Surgical Quality Improvement Program. Support EMR development to allow inquiries of the patient data- • base for clinical research. Collaboration of Healthcare Professionals Sector with Other Sectors Clinical Investigators Interact to expand the clinical base from which evidence is gener- • ated to include a wide range of practice settings and observational data. Support the federal funding of research on outcomes from the • implementation of EBP. Encourage research on the dissemination of EBP and the implemen- • tation of best practices. Release major new guidelines simultaneously with the findings of a • funded research trial for evaluation of defined practice outcomes. Support the development of evidence-based guidelines in areas • in which few or none exist (e.g., for patients with multisystem diseases and for the screening and treatment of children and ado- lescents for whom the chances of positive outcomes of a disease process are remote). Several systematic reviews have documented the relatively small • number of studies and the poor quality of research evaluating the effectiveness of interventions to increase the rate of use of EBP. Support for research into innovative approaches to changing the behavior of healthcare professionals with rigorous outcome evalu- ation is essential. Information Technology Work with IT developers to develop a common vocabulary and • interoperable technologies to allow information sharing. Interact with IT developers to improve EBM guideline interfaces • to reduce redundant data entry and to screen changes and forced recommended practices, and provide areas for documentation for exceptions. Include healthcare practitioners in the design and development of • IT support systems.

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 HEALTHCARE PROFESSIONALS Consumer-Patient Support the concept of the use of observational patient data as • evidence for the healthcare system. Encourage the development of patient materials to support con- • sumer adoption of evidence-based health concepts and practice. Support the development of robust methods to include patient • values and preferences in complex decision making. Insurers Encourage the use of performance feedback to adjust rates. • Endorse industry support of a transition to EMR with robust • decision support at the point of care. Support payer endorsement and the support of professional efforts • to promote changes to the medical culture. NEXT STEPS The adoption of EBP, including the shift to patient-centric care, will require nothing short of a transformation of current medical practice. In this transformation, healthcare professionals can be described as the criti- cal transition point between current healthcare practice and the delivery of evidence-based care. This chapter on the healthcare professionals sector has identified a number of model initiatives that are already under way in a variety of settings to support this process. The chapter has also highlighted key actionable items that will further support the initiation of change. However, to truly make this kind of culture change possible, sustained effective leadership will be essential. To that end, we propose the appoint- ment of an EBM Interdisciplinary Healthcare Professionals Advisory Panel to interact with the leadership at the IOM. The panel would serve as the voice of the healthcare professionals sector in education, practice, and regulatory oversight. The panel would be charged with establishing criti- cal initial steps; identifying benchmarks to define progress; and developing future initiatives in education, practice, and regulatory oversight to sustain the process of adoption of EBM as it evolves. The creation of this panel would represent a new coordinated starting point for an integrated shift to EBP for the healthcare professionals sector. Proposed Panel Format We propose that the members of the panel play roles in education and in the practice setting and that they also have an oversight role. In the area

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2 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE of education, leaders in the undergraduate and postgraduate education of healthcare professionals would be charged with the development and imple- mentation of a coordinated set of strategies that would support lifelong learning in EBP throughout the healthcare professions’ education. Their initial role would be to consult in development of the EBM public educa- tion campaign. Proposed members could come from among the following groups: ACGME; American Academy of Nursing; American Association of Medical Colleges, including the Council of Deans; American Boards of Internal Medicine, Pediatrics, Family Practice, Surgery, and so forth; Commission on Collegiate Nursing Education; National Council of State Boards of Nursing; National League for Nursing; National Organization of Nurse Practitioner Faculties; and professional societies such as the Ameri- can Academy of Pediatrics, American Association of Colleges of Nursing American College of Cardiology, American College of Pharmacy, Ameri- can College of Surgeons, and Society of Thoracic Surgeons. IT developers, health practitioners, and leaders from the whole range of healthcare settings and professional organizations would be charged with working together on the design and development of support for EBP, including the development of a culture that supports EBP. Health insurance providers and healthcare regulators would be charged with the development of incentives to facilitate practice change. Representatives from all those groups involved in the regulation and oversight of competence at all levels of healthcare professional training and practice would be charged with ensuring the vertical integration of competencies in EBM throughout basic and clinical training and postgradu- ate certification. Regulatory groups from which potential members would be selected include the National Board of Medical Examiners; ACGME; specialty and subspecialty boards; and state medical licensing systems for physicians, nurses, and pharmacists. Summary: Healthcare Professionals This chapter has outlined a strategy that can be used to increase the training of new healthcare professionals and those already in practice in EBP, improve IT support for EBP, enhance healthcare system cultures that support EBP, and increase the rates of participation of healthcare profes- sionals in medical evidence generation as standard care. The chapter has also described specific initiatives that address this dual strategy at each stage of training or practice and has provided examples of benchmark programs that address aspects of these priorities. The use of a public information cam- paign as a way of introducing all practicing healthcare professionals and the American public simultaneously to the concepts of EBP, with reinforcement by the use of CME, educational incentives, and feedback from inquiring

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 HEALTHCARE PROFESSIONALS patients and the development of partnerships with existing educational, IT, and practice research organizations will be important steps in supporting routine EBP, something that is already under way in many settings. This review indicates that current models of excellence can be used to increase the rate of implementation of EBM. Whenever possible, these should be used to enhance this process. A combination of support for the required technology, the provision of rewards for improved performance, the provision of regulatory oversight, and increased participation in the generation of clinical research data are proposed as the most effective ways to sustain progress toward this important goal. Finally, appointment of an EMB Interdisciplinary Healthcare Professionals Advisory Panel is recommended as the critical first step in providing sustained leadership for initiation of the process needed to maximize the adoption of EBM in clinical practice. REFERENCES Accreditation Council for Pharmacy Education. 2006. Accreditation standards and guide- lines for the professional program in pharmacy leading to the doctor of pharmacy degree. http://www.acpe-accredit.org/pdf/ACPE_Revised_PharmD_Standards_Adopted_ Jan152006.pdf (accessed July 10, 2007). ACGME (Accreditation Council for Graduate Medical Education). 1999. ACGME Outcomes Project. Common program requirements: General competencies. http://www.acgme.org/ outcome/comp/compMin.asp (accessed April 18, 2007). Aiken, L. H., S. P. Clarke, R. B. Cheung, D. M. Sloane, and J. H. Silber. 2003. Educational levels of hospital nurses and surgical patient mortality. JAMA 290(12):1617-1623. American Association of Colleges of Nursing. 2006. Position statement on nursing research. http://www.aacn.nche.edu/Publications/positions/NsgRes.htm (accessed May 28, 2007). American Association of Colleges of Pharmacy. 2007. Report of the AACP educating clinical scientists task force. Paper read at AACP Annual Meeting, July 2007, Orlando, FL. American Board of Internal Medicine. 2007. Maintenance of certification. http://www.abim. org/moc/default.aspx (accessed April 23, 2007). American College of Clinical Pharmacy. 2000. AACP white paper. A vision of pharmacy’s future roles, responsibilities, and manpower needs in the United States. Pharmacotherapy 20(8):991-1020. American College of Physicians. 2005. Physician employment trends. In Trends in medicine and health. Philadelphia, PA: Office of Research, Planning and Education, American College of Physicians. American Hospital Association. 2006. The state of America’s hospitals: Taking the pulse. Findings from the 200 AHA survey of hospital leaders. http://www.ahapolicyforum. org/ahapolicyforum/resources/content/StateHospitalsChartPack2006 (accessed May 21, 2007). ASHP (American Society of Hospital Pharmacists). 2006. Regulations on accreditation of pharmacy residencies. http://www.ashp.org/s_ashp/cat1c.asp?CID=3531&DID=5558 (accessed July 10, 2007). Audet, A. M., M. M. Doty, J. Shamasdin, and S. C. Schoenbaum. 2005. Measure, learn, and improve: Physicians’ involvement in quality improvement. Health Affairs 24(3):843-853.

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