Volume 8, Issue 3 , Pages 181-185, September 2008
Learning at the Point of Care Using Evidence-Based Practice Resources and Clinical Decision Support
Article Outline
- Abstract
- Evidence-Based Practice
- Clinical Decision Support
- Credit for Learning at the Point of Care
- Implications for Evidence-Based Dentistry
- References
- Copyright
Leaders in the field in academic settings, professional associations, and those who determine criteria for CE credit should discuss implications and work together to establish appropriate processes to promote learning at the point of care. Clinical decision support and point-of-care learning based on evidence-based practice recommendations reduce variability in care, reduce errors, improve safety, and ultimately improve the quality of patient care.
Key words: Point of care, CME, evidence-based continuing eduction, evidence-based practice, clinical decision support
Since the earliest documentation of continuing medical education (CME) in 1947 by the American Academy of General Practice (now the American Academy of Family Physicians [AAFP]), the goal of continuing education (CE) has been to ensure that clinicians keep up with changes in clinical evidence and improve patient care.1 Through the years, continuing education has moved farther and farther away from the point of care. The commercialization of CE has moved it out of the clinical setting and into the hotel ballroom, or in worse cases, onto ski slopes and cruise boats. With the introduction of evidence-based practice, Internet-based learning, clinical decision support, and health care quality improvement, staying abreast of new clinical information is moving back into practice.
Evidence-Based Practice
Evidence-based practice (EBP) in dentistry is modeled after evidence-based medicine (EBM) first described by David Sackett and his peers at McMaster University in the early 1990s. While controversial when it was first introduced in medicine, there has been acceptance in recent years and Sackett et al's2 2000 modified definition is now core in medical education: evidence-based medicine is the integration of best research evidence with clinical expertise and patient values. It is important to acknowledge each of the 3 components of the definition as equally important for quality clinical care. The American Dental Association (ADA) defines evidence-based dentistry as an approach to oral health that requires the judicious integration of: systematic assessments of clinically relevant scientific evidence, relating to the patients oral and medical condition and history, together with the dentist's clinical expertise and the patient's treatment needs and preferences.3
An evidence-based approach is a stepwise process:
There are challenges with evidence-based practice in both medicine and dentistry. First, there are limitations in available scientific evidence. Much of what is practiced has not been studied with randomized control trials (RCTs), nor would it be appropriate to do so in all clinical areas. Evidence changes rapidly, with new technologies, medications, and other treatment modalities being developed and implemented at a rapid pace. It is difficult to disseminate new evidence into practice. With the plethora of new clinical information published daily, clinicians have difficulty keeping up and many practice without benefit of the latest evidence. This leads to variation in the quality of care provided to patients. Finally, clinicians often don't trust the evidence, believing that the research environment leading to practice recommendations is artificial and irrelevant to actual practice. Shaughnessy et al4 described the clinical information usefulness equation as
The usefulness of clinical data must be relevant to practice, have proven validity, and be easy to obtain. Because clinicians may lack the skills necessary to critically appraise the literature, it is difficult to recognize good studies from less effective ones. And they simply do not have time to read and assess all the available evidence. For that reason, several evidence-based medicine resources have been developed and are becoming more and more available at the point of care. Perhaps the first and still the gold standard is the Cochrane Library, formed in the United Kingdom in 1993 in response to a call by Archie Cochrane for up-to-date, systematic reviews of all relevant randomized controlled trials of health care.5 The Cochrane Collaboration establishes criteria for critical appraisal of literature in various clinical areas, brings together volunteer content experts from around the world to perform systematic reviews, and promotes evidence-based recommendations published in the Library. The Cochrane Oral Health Group registered with the Collaboration in 1994 to produce systematic reviews that primarily include all RCTs of oral health, broadly defined as the prevention, treatment, and rehabilitation of oral, dental, and craniofacial diseases and disorders. In the past 15 years, many more resources have been developed, thus reducing the “work” component of the usefulness equation. These resources are easily searched via the Internet and provide strength (level) of evidence to support their recommendations. A full list of oral health systematic reviews is available at http://www.ada.org/prof/resources/ebd/reviews/index.asp with additional evidence-based dentistry resources available at http://www.ada.org/prof/resources/ebd/resources.asp.
Clinical Decision Support
Clinical decision support (CDS) is defined as providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered or presented at appropriate times, to enhance patient care.6 The goal is to provide tools to assist clinicians with evidence-based clinical decision making at the point of care. These tools improve the quality of care and help to eliminate errors. Most CDS is computer-based, often integrated into the patient's clinical record to allow real-time decision support. Examples of tools include:
CDS tools offer aid to busy clinicians in the form of reminders, alerts, or new information to allow timely, evidence-based clinical care. While tools can be effective when used outside the patient record, they are most useful when integrated into the record allowing for individualized patient management. Some early experience in medicine has shown adoption to be spotty at best. Clinicians frequently ignore, override, or fail to seek out suggestions that could improve care.7 The most effective implementation of clinical decision support seems to be in reduction of medication errors and adverse drug events, enhancing prescribing behavior, improving compliance with clinical pathways and guidelines, and improving efficiency in some health care delivery processes. While CDS is a form of artificial intelligence, its intent is to augment clinical judgment, not replace it. In addition to assisting with a clinical decision at the point of care, CDS can provide new knowledge leading to competence that is immediately transformed into improved performance in patient care.
Credit for Learning at the Point of Care
In 2005, the American Medical Association and the American Academy of Family Physicians, each with their unique CME credit systems, agreed to implement similar criteria for awarding CME credit for learning at the point of care.8, 9 These criteria were based on the stepwise approach to evidence-based practice: (1) ask a clinical question; (2) search best evidence for the answer; (3) critically appraise the evidence; (4) integrate the evidence with clinical expertise and patient needs; (5) evaluate results. Evidence-based, Internet-based CDS and other clinical information resources provide a means for answering clinical questions at the point of care. Giving a physician the opportunity to answer a question posed by a particular patient's case, finding the answer to that question, and implementing the recommendation in real time is the ultimate solution to meeting that physician's educational needs. Providing rewards in the form of CME credit for such effective learning has become a method for moving CME from questionable effectiveness to proven effectiveness, one patient at a time.
As with all credit, the devil is in the documentation. Since point of care learning is computer-based and Internet-based, systems for documentation are fairly easily implemented. In order to award credit, the CME provider must document the physician's clinical question, the search that yielded the answer, and how the answer was applied in practice. In some cases the recommendation may not have been implemented because the physician did not feel it was appropriate for the patient or the patient declined. As long as it is documented, this is still allowable for credit. While Internet-based resources typically capture the clinical question (at least key words) and search strategies, the challenge has been with documenting application to patient care. Most systems allow drop-down boxes with choices of how the recommendation was used, or not, depending on the situation. Credit is not based on time, as other traditional CME formats have been, but simply awarded as 0.5 credits per documented clinical question. Physicians are limited to 20 credits annually from point-of-care learning activities.
Challenges with implementation of point-of-care CME credit have largely been around documentation. Providers of evidence-based clinical sources complain that documentation for credit creates a barrier for users. Physicians often don't need additional CME credit and therefore don't want to complete the documentation steps required. Ensuring that sources are up-to-date and evidence-based are other concerns. The AAFP requires sources be approved before they allow credit for using them. The American Medical Association has no such requirement, choosing instead to allow CME providers to determine which sources are allowable for credit. Examples of noncommercial sources currently used in point of care CME include the Cochrane Library, the US Preventive Services Task Force, the National Guidelines Clearinghouse, and medical specialty society journals and other educational content databases. Two examples of proprietary, subscription-based products are UpToDate and PEPID (both offer evidence-based oral health recommendations). Additionally, some services offer opportunities for searching multiple databases and then provide electronic documentation for point-of-care CME credit. One such service is eeds (Electronic Education Documentation System). Examples of their documentation process are shown in Figure 1, Figure 2, Figure 3.
Figure 1.
Log point-of-care learning.
Figure 2.
Log point-of-care learning.
Figure 3.
Log point-of-care learning.
The decision to award CME credit for point of care learning was not to make additional CME credit available to physicians, but rather to give added value to a learning methodology that has direct and immediate impact on improving patient care. Leaders in the field in academic settings, professional associations, and those who determine criteria for CE credit should discuss implications and work together to establish appropriate processes to promote learning at the point of care. Clinical decision support and point-of-care learning based on evidence-based practice recommendations reduce variability in care, reduce errors, improve safety, and ultimately improve the quality of patient care.
Implications for Evidence-Based Dentistry
There are many evidence-based practice resources available in oral health that could support continuing dental education at the point of care. Leaders in the field in academic settings, professional associations, and those who determine criteria for CE credit should discuss implications and work together to establish appropriate processes to promote learning at the point of care. Clinical decision support and point-of-care learning based on evidence-based practice recommendations reduce variability in care, reduce errors, improve safety, and ultimately improve the quality of patient care.
References
- . Constitution and bylaws: article 1. Kansas City, MO: American Academy of General Practice; 1947;
- . Evidence-based medicine: how to practice and teach EBM. 2nd edition. London: Churchill Livingstone; 2000;
- American Dental Association. Evidence-based dentistry: glossary of terms. Available at: http://www.ada.org/prof/resources/ebd/glossary.asp#ebd. Accessed March 15, 2008.
- . Becoming a medical information master. J Fam Prac. 1994;38(5):505–513
- Cochrane Collaborative. Available at: http://www.cochrane.org/. Accessed March 15, 2008.
- Trowbridge R, Weingarten S. Clinical decision support systems. In: Evidence Report/Technology Assessment No. 43. Making healthcare safer: A critical analysis of patient safety practices. Washington DC: AHRQ; 2001. Chapter 53. Available at: http://www.ahrq.gov/clinic/ptsafety/chap53.htm. Accessed March 2008
- . Diagnostic decision support systems: Why aren't they used more and what can we do about it?. Washington, DC: American Medical Informatics Association Proceedings; 2006;
- American Academy of Family Physicians. Activities Eligible for Prescribed Credit. Available at: www.aafp.org/online/en/home/cme/cmea/cmerequirements/prescribedcredit.html#Parsys000. Accessed March 26, 2007.
- American Medical Association Physicians Recognition Award. Available at: www.ama-assn.org/ama1/pub/upload/mm/455/pra2006.pdf. Accessed March 2008.
PII: S1532-3382(08)00126-7
doi:10.1016/j.jebdp.2008.06.003
© 2008 Elsevier Inc. All rights reserved.
Volume 8, Issue 3 , Pages 181-185, September 2008