Sand dunes overlooking the Atlantic Ocean. Cape Cod National Seashore (US National Park Service). Massachusetts
The CEO of your health care system has cut all unit budgets by 25%, forcing you to cancel one of two popular Point-of-Care resources. The more established health care providers prefer the first resource, while the newer providers and residents prefer the second resource.
Morale is low among providers in your health care system, with their discontentment primarily stemming from electronic health records, particularly the overwhelming volume and frequency of automatic alerts. Federal laws or regulations mandate some of these alerts.
The Vice President of Research is interested in gauging the impact of your resources and services on the success of the research enterprise within your institution.
The Academic Dean is seeking ways to reduce the number of contact hours in the curriculum while still meeting all national competencies for graduating seniors. You are responsible for ensuring that all students meet their national competencies in Evidence Based Practice. What content can you safely reduce or even eliminate?
How would you make these decisions? Evidence Based Practice (EBP) has proven to be a reliable framework for making these types of important decisions. EBP provides a sequential and structured approach for integrating the best available evidence into the decision-making process. Typically, this process entails formulating an answerable question, searching for the best available evidence, critically evaluating the evidence for both its relevance and quality, and then reaching a decision unhindered by the myriad of challenges often encountered when making sound decisions.
EBP has undergone significant transformations since its inception a couple of decades ago. In its early stages, EBP tended to be more speculative or prescriptive rather than based on concrete experience. Some of the earliest works, including some of my own contributions, now seem quaint and naïve. Nevertheless, many of these early works harbored visionary ideas that inspired efforts to bring about the remarkable developments that define EBP today. The most striking developments in EBP are found in the areas of question formulation and the search for evidence. These areas exemplify the most profound changes that have taken place within EBP. Our evidence base has grown tremendously in breadth and in rigor.
Not everything within EBP has undergone a transformation, however. While the definition of EBP has evolved to a more refined state, its fundamental components have remained intact. The EBP process follows the same well-traveled path, although it no longer places emphasis on the final reflection step for every decision. Reflection maintains its significant role, existing separately from EBP yet interwoven into other facets of professional practice.1
provides a visual depiction of the current EBP process, consisting of formulating a question, searching for the best available evidence, appraising the quality of the most relevant evidence, and reaching an individual or group decision.
EBP maintains its three-part structure as the guiding framework that encompasses the practitioner, the evidence, and those parties to whom these practitioners are held accountable. portrays this tripartite framework of EBP. Within this EBP framework, practitioners draw upon their extensive repertoire of skills, knowledge, experiences, and professional judgment. Additionally, practitioners strive to adhere to their values, which will be further elaborated upon in this chapter. The evidence, described throughout this Guide, must be compelling and convincing to those individuals or groups to whom practitioners are answerable. This third corner of the triangle, Accountable Parties, includes leaders who govern or oversee the practitioners. It also encompasses a diverse assortment of people who either currently depend on or who might someday rely on the services or resources the practitioners provide. While the commonly-used term “stakeholders” is used in this Guide, it does not accurately capture the diverse and, at times, challenging-to-identify populations in the third corner in . Nevertheless, for the sake of simplicity, the short-hand term “stakeholder” will be used throughout this Guide.
1.1 Audiences
This Guide aspires to be a valuable resource for various audiences: newcomers to the field, experienced colleagues with incomplete knowledge of EBP, and experienced practitioners already engaged in EBP who seek a convenient reference. Health Information Professionals (HIPs) bring diverse skills and interests to their roles, from health sciences librarianship, informatics,2 information science, archival managers, and others who do not fit neatly into these categories. This Guide seeks to advance EBP further by consolidating the essential components of the EBP approach to decision-making into a single source. It draws upon and builds upon earlier EBP work for HIPs.3,4,5 Readers will recognize familiar and enduring elements within this Guide that continue to define EBP.
This Guide sets a unique course that diverges away from these other fine works. This Guide focuses on two distinct core elements. Firstly, this Guide restricts its scope to the United States (US), recognizing the distinctive history and health care landscape of the country. Secondly, this Guide primarily serves the needs of HIPs within the vast US health care system. HIPs support clinical, educational, and research facets of this extensive system, which remains a vast realm of work, especially in a diverse nation of over 330 million people.6 A substantial portion of the content in this Guide might prove helpful to colleagues apart from the health sector or from outside the US. While this Guide offers a comprehensive and interconnected resource for HIPs within the US, readers from outside the health sector or HIPs in other countries should exercise discernment to ensure the suitability of any elements they select to apply to their respective sectors or nations.
The narrower scope of the Guide reflects my extensive collaborative experiences with EBP colleagues outside the US over the past two decades. I had the opportunity to contribute chapters to both the 2004 Booth and Brice7 text and the 2016 Koufogiannakis and Brettle book.8 These authorship experiences, combined with my many collaborations with colleagues from Sweden, Canada, Italy, and the UK, convinced me that the health care environments and professional cultures in these nations differ significantly from what HIPs experience in the US. To maintain a purposeful direction tailored to HIPs in the US, I intentionally chose a more focused approach for this Guide.
1.2 Tradition of Research
A Swedish colleague with an interest in EBP wrote, “I have always seen the lack of published [research] evidence about Swedish/ Scandinavian libraries and in Swedish/ Norwegian/Danish as a huge obstacle …”9 The presence of research evidence in the US predates the emergence of EBP by more than 50 years. Brodman employed a form of survey called “reputational analysis” as an alternative to the then-prevalent citation analyses.10 Postell pioneered the cohort study to predict future resource usage.11 Forty-three years ago, the Medical Library Association President, Erika Love, elevated research to one of the three highest aspirations of the profession.12 In 1981, Marshall implemented the first-ever randomized controlled trial in our profession.13
Two prominent factors appear to drive the growing emphasis on research within the health information profession in the US. First, at any moment HIPs have come under scrutiny from external stakeholders who place a high value on empirical research. As Chapter 2 indicates, the leaders and the many users of HIPs’ services and resources are well-versed in clinical research methodologies. They possess a solid understanding of observational and experimental study designs within their respective professional domains. The second reason appears to be the historical pattern of many health sciences librarians serving as faculty members. These faculty members, or their HIP colleagues with similar academic status, have been encouraged and are often expected to conduct original research.14,15
1.3 Values
Why did you choose to become a HIP? Surely not for the pursuit of power, prestige, or wealth! Most HIPs appear to be driven by a shared passion for the organization and accessibility of information to those in need. Beyond these common goals, it appears that HIPs share some common values, many of which align with the widely held values in both the health and scientific sectors. These values include integrity, honesty, equity, humility, skepticism, and accountability. HIPs subscribe to the definition of health as a “state of complete physical, mental, and social well-being and not merely the absence of disease.”16 HIPs join physicians, nurses, therapists, public health experts, and all other health professionals in striving to provide the highest standard of care to all patients. Similar to their scientific research colleagues, HIPs exhibit a considerable interest in replicability and reproducibility. Replicability entails another researcher’s ability to conduct an identical study to yield identical results, while reproducibility involves a researcher’s provision of protocols, code, and data used in a study, allowing others to scrutinize it.17
HIPs generally subscribe to American Pragmatism, as first articulated by William James. Pragmatism emphasizes a focus on the practical consequences of any theory or principle, while also highlighting the importance of real-world experiences coupled to the practical applications of abstract concepts.18 The roots of Pragmatism can be traced back to the nations that populated the US before European contact, with subsequent adoption by European settlers on this continent.19 The HIP visionary, John Shaw Billings, applied a pragmatic approach in his contributions to the development of punch cards20 and his creation of Index Medicus, which eventually evolved into the informatics achievement known as MEDLINE.21 Today, HIPs continue to adopt a pragmatic approach across their multifaceted roles.
HIPs hold a profound regard for the accessibility of information for all who desire it. This deep-seated commitment to open-access information can be traced back to the early stages of the profession’s development, exemplified when John Cotton Dana challenged conventional norms by refusing to be a physical gatekeeper to information.22,23 HIPs continue this dedication to open access through advocacy and concrete efforts to ensure that the evidence at the center of EBP can be made freely available to all. These values have withstood the challenges and transformations that have characterized the past three decades. HIPs draw upon these values, together with their expertise and the best available evidence, to inform their EBP decisions.
References
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Chicago: Neal-Schuman, an imprint of the American Library Association; 2016.
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Cambridge, Mass: Harvard University Press; 1978.
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CB. Order Out of Chaos: John Shaw Billings and America’s Coming of Age.
Boston: Boston Medical Library in the Francis A. Countway Library of Medicine; 1994.
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Newark, NJ: The Public Library and Museum, 1940.
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