Health informatics and evidence based practice (don't need to regurgitate but understand)

Question 1

Evidence based medicine definition

Answer 1

-The conscientious explicit and judicious use of evidence in making decisions about the care of individual patients

Question 2

What 3 concepts did evidence based medicine challenge?

Answer 2

-Clinical freedom
-Doctor knows best
-Established practice

Question 3

How do we synthesise information into evidence?

Answer 3

-Hypothesis generating and experiments
-Replicating experiments
-RCTs

Question 4

Hierarchy of experimental evidence pyramid (EXAM)

Answer 4

Question 5

Features of electronic patient record

Answer 5

-Clinical decision support systems - CDSS
-Learning health system - AI/machine learning
-Etiquette of consulting with computer screen

Question 6

4 Vs of big data

Answer 6

-Variety
-Volume
-Velocity
-Veracity

Question 7

What is implementation science?

Answer 7

-The scientific study of methods to promote the systematic uptake of research findings and other evidence based practices into routine practice
-To improve the quality and effectiveness of health services

Question 8

What is the WHO surgical safety checklist?

Answer 8

-Ensures patients are protected from risks during surgery

Question 9

What is the Cochrane library?

Answer 9

-Database of systematic reviews of RCTs

Question 10

Features of evidence based medicine

Answer 10

-Translation of uncertainty to an answerable question and includes critical questioning, study design and levels of evidence
-Systematic retrieval of best evidence available
-Critical appraisal of evidence for internal validity that can be broken down into a range of aspects

Question 11

Characteristics of RCT

Answer 11

-Population selection - as few competing health and social issues as possible
-Randomisation - participants randomised to intervention or control groups
-Conduct - participants in both groups dealt with in comparable ways
-Number of participants allow analysis to show a difference between the 2 groups

Question 12

Pros and Cons of RCT

Answer 12

Pros
-Accurate, unbiased measurement of treatment effect
-High degree of internal validity
-Strict eligibility criteria - homogenous study population
-Accurate measurement of treatment effect
-Reduced inter-patient variability

Cons
-Suboptimal representation of patients treated in real world setting
-Most marked in patients with advanced age or greater comorbidities

Question 13

What is a systematic review

Answer 13

-Methodical and comprehensive way of synthesising existing research on a particular topic/question
-Aims to identify, evaluate and summarise the findings of all relevant studies in a transparent and unbiased manner

Question 14

Steps in a systematic review

Answer 14

-Begins with a research question
-To answer question, a comprehensive search for all publications relevant to question
-May be 5000 references identified
-Usually less than 20 references are relevant
-Evidence is synthesised and summarised

Question 15

What is a meta analysis?

Answer 15

-Usually conducted within a systematic review
-Quantitative, formal, epidemiological study design used to systematically assess the results of previous research to derive conclusions about that body of research
-Statistical integration of evidence from multiple studies that address a common research question

Question 16

Features of clinical guidelines

Answer 16

-Made the volume of research manageable for the individual clinician
-Resolved clinician’s disagreement on appropriate management
-Funding from special interest groups and government

Question 17

Why the need for NICE?

Answer 17

-Address inappropriate variations in clinical practice and “post code” access to expensive treatments
-Support clinicians to keep up to date with relevant new evidence
-Assess the value (cost effectiveness) of new and existing treatments
-Encourage innovation

Question 18

What are QALYs?

Answer 18

QALY = added life x quality during that added time
Added duration of life quality of that life quality from 0-1
0 = no quality 1 = full quality

Question 19

What does NICE value cost of QALY?

Answer 19

-Treatments that cost between £20000 and £30000 per Quality adjusted life year (QALY) represent good value for money

Question 20

How are NICE guidelines formed?

Answer 20

Distillation of:
-Expert opinion
-Observational studies
-Cohort and case control studies
-Systematic reviews
-RCTs

Question 21

What is a learning health system?

Answer 21

-Advanced approach to healthcare where data and experiences from clinical practice are continuously collected, analysed and used to improve patient care

Question 22

What is in electronic patient record (EPR)?

Answer 22

-Patient’s demographic data
-Biometric data
-Disease and treatment data
-Presenting history
-Examination data

Clinician’s action:
-proposed diagnosis, investigation, treatment

Question 23

What happens when evidence is implemented?

Answer 23

-replace a behaviour
-reject a behaviour
-adopt a new behaviour
-individual, group or system level

Question 24

How could you change the behaviour of prescribing?

Answer 24

-Install a pop up in the computer
-Block the prescribing of the expensive versions of the drug within the NHS
-Provide an educational programme for all prescribers
-Run a national media programme to inform patients what to expect
-Prevent the dispensing by chemists of the more expensive statins without justification

Question 25

What are obstacles to implementation?

Answer 25

-Lack of leadership -Lack of necessary resources -Lack of experience in the executors of the implementation plan -Inadequate planning -Disorganised work structure -Poor readiness to change -Poor team structure -Lack of commitment -Lack of prioritisation

Question 26

Efficacy vs Effectiveness

Answer 26

Efficacy (in theory) -the power or ability to produce an effect -best tested in medicine with a RCT Effectiveness (in real world) -the degree to which something is successful in producing a desired result -best tested in medicine with a 'real' world trial

Question 27

What is the efficacy - effectiveness gap?

Answer 27

-Describes the differences in outcomes between patients treated in RCTs and those treated in the 'real world' -In an RCT, everything is arranged to represent an ideal -In real world trials the experiment is messy because the restrictions on participants, staff and patients, is much less

Question 28

RCT summary

Answer 28

-Experiment to reduce bias when testing treatment efficacy -Random allocation of subjects to 2 or more groups -Treat them differently, compare the response -The experimental group - receives the intervention (e.g. a drug) -The control group - receives an alternative (placebo) -The groups are monitored to determine the efficacy of the experiment

Question 29

Areas of implementation

Answer 29

-Individual clinician -Local groups -Professional groups -Organisation -Region -Society

Question 30

Factors which facilitate implementation

Answer 30

-Experienced leadership -Detailed planning -Team engagement -Prioritisation -Provision of required resources

Question 31

Factors which are obstacles to implentation

Answer 31

-Lack of commitment by management -Disorganised work culture -Poor readiness to change -Poor team structure

Question 32

Clinical decision support systems (CDSS) definition?

Answer 32

“Clinical decision support systems link health observations with health knowledge to influence health choices by clinicians for improved health care”

Question 33

What actually are CDSS?

Answer 33

-Computer algorithms -‘Execute’ rules -Clinician prompted by system about a way to improve care

Question 34

What is the pyramid of evidence

Answer 34

-CDSS keep on top of this pyramid of literature

Question 35

Evolution of recording information

Answer 35

Paper records -> Electronic records plain text -> Electronic records coded (SNOMED)

Question 36

What is SNOMED?

Answer 36

-Standardised vocabulary with definitions and references -Allows you to write rules for results

Question 37

What can CDSS allow you to do?

Answer 37

-Identify patients in risk groups -Offer them a referral -Create alert for this referral

Question 38

How can CDSS be used in prescribing?

Answer 38

-Warn clinicians of drug interactions/contraindications -Recommend preferred brand to save money -Alert about dosing regime -Test renal profile before certain drugs

Question 39

What is alert fatigue?

Answer 39

Too many alerts can: -Waste time -Confuse clinicians -Worsen patient care

Question 40

Types of bias in big health data

Answer 40

-Collection data used for multiple purposes -Patient information may not be complete, accurate or current -Reimbursement bias -Data extraction/processing -Research dataset/methodologies -Practice workload

Question 41

Obstacles in big data collection

Answer 41

-Restrictive policies on data access -Licences for data access can be expensive -Lack of standard policy on patient data privacy/confidentiality -No international standardisation on data collection routes

Question 42

Challenges of research data management

Answer 42

-Insufficient incentive for researchers to publish datasets -Governance models outdated and too restrictive, with little or no audit of adherence -Lack of awareness of data available to researchers within institutions -Little or no provenance captured during data analysis -Poor data management and lack of coherent analytical software strategy

Question 43

AI in medicine

Answer 43

-Computers can identify patterns faster and in greater numbers -Function of speed, opposed to intelligence

Question 44

Challenges of AI

Answer 44

-Limited by nature of available training data for AI -Autophagia of AI (training on its own outputs) -Data provenance (what was my AI algorithm trained on?) -Digital inequalities -Potential bias

Question 45

Features of learning health systems

Answer 45

-Learn from every patient encounter -Improve the care that patient receives, their family receives, their community receives -Creates a feedback cycle that enables "Evidence Generating Medicine" across and between scales of measurement and decision-making