Roberto J.

Rodrigues

Information Systems: Enabling Factor for

Evidence-Based Health Practice
Increasing prominence is being given to the use of best current evidence in decision
making, both in clinical practice and healthcare management. A review of the main
issues related to Evidence-Based Practice (EBP) and a discussion on how to
develop, validate, promote, and use evidence and knowledge in clinical and
administrative settings are presented. The role of information systems, and the
challenges that must be met in the implementation of Information Systems and
Information Technology (IS&T) and knowledge management tools, are examined for
six application areas: Reference Databases, Contextual Data, Clinical Data
Repositories (Clinical Databases), Administrative Data Repositories, Decision
Support Software, and Internet-Based Interactive Health Information. Computerized
applications in support of EBP must follow a hierarchy in which systems tasks range
in complexity, from reference retrieval and the processing of relatively routine
transactions, to complex decision-support systems.

The Evidence-Based Practice Movement
Most clinical practice, is based on limited evidence,
mostly textbook information, obsolete concepts,
nonvalidated case studies, partial or unendorsed
reviews and abstracts, and anecdotical or individually
accumulated clinical experience. Proven therapies
backed by ample evidence are underutilized due to
lack of knowledge or grasp of available evidence and,
frequently, clinicians do not believe that benefits
observed in clinical trials can be translated into
clinical practice (1).
Evidence-based practice (EBP), which gained impetus
in the early 90’s, replaces the traditional paradigm of
“medicine by authority”, by a more critical and
scientific approach (2,3).
A major contribution to the call for a more rational
approach to clinical decision-making was the growth
in clinical, administrative, outcomes research, and
investigation into the determinants of healthcare costs.
These developments have made it mandatory for
healthcare professionals and managers to be aware,
appraise, and systematically make use of published
data (4).
EBP can be seen as a process of turning
clinical problems into questions and
systematically locating, appraising, and
using contemporaneous research and
critical reviews, i.e., the best evidence
possible and the most appropriate
information available as the basis for
decisions.

The EBP movement is an effort to teach direct care

Dr Rodrigues is Regional Advisor in Health Services
Information Technology, Essential Drugs and Technology
Program, Division of Health Systems and Services
Development, Pan American Health Organization / World
Health Organization, Washington, D.C.,USA
professionals to evaluate research evidence and apply
it to clinical activities – it requires that the results of
primary research be compiled in a methodical way
and made accessible to those involved in the decision-
making process (5).
 2
EBP values, enhances, and builds on clinical
expertise, facts about disease mechanisms, and human
pathophysiology. Failure to use evidence has been
show to result in a considerable lag period before
therapies of proven effectiveness are implemented or
ineffective therapies are withdrawn from practice.
Ultimately, EBP represents the formalization of the
care processes that the best clinicians have practiced
for generations (3).
The introduction of evidence-based clinical practice
has had a positive impact on medicine and pharmacy –
drug therapy being perhaps one of the most significant
areas influenced by EBP. Evidence-based practice
concepts have been adopted in physician’s training
programs that place emphasis in problem-solving and
information search skills (6,7,8).
Information Systems Support to
Evidence-Based Practice
The role of information systems is to capture,
transform, and maintain three levels of facts: raw data,
processed data, and knowledge (9). Data in context, as
processed data, is traditionally referred as
“information”. Information conveys intelligence about
a particular topic and can be considered the equivalent
of “evidence”. Knowledge is information in context. It
represents an intellectual construct of a higher order,
where evidence from various fields and sources are
linked, validated, and correlated to established
scientific truths and thus becoming a generally
accepted body of wisdom.
Because EBP is an information- and
knowledge-intensive process, focusing
attention on evidence-based practice from
an informational perspective and the
implementation of an information
infrastructure (“infostructure”) in the
clinical and administrative practice
environment constitute the core of the
contribution of informatics to EBP.
Information and knowledge management constitutes
the core activity of the healthcare professional. To put
the problem of information, as an essential support
component to appropriate decision making, in proper
perspective, consider the costly mistakes that stem
from incomplete information – of the roughly one
trillion dollars spent in healthcare in the United States
in 1998, an estimated 25% relates to the delivery of
unnecessary or avoidable care, the performance of
redundant tests, and excessive administrative costs.
Information Systems and Information Technology
(IS&T) contributions to EBP is accomplished in six
areas of application (Figure 1):
• Reference Databases
• Contextual Data
• Clinical Data Repositories
• Administrative Data Repositories
• Decision Support Software
• Internet-Based Interactive Health
Information
Reference Databases: Literature, Clinical Trials
and Reviews, Current Research, and Guidelines
Most of the literature on EBP emphasizes the
utilization of published evidence, usually restricted to
papers, reports, and research recorded in formal
technical or scientific sources (7,10,11,12,13,14,15).
Basic research and clinical observational data and
evidence are represented in the biomedical literature
(books and periodicals), in the formal publications of
scientifically conducted clinical trials and reviews,
and in the formal records of current research
initiatives. Jointly, they represent a body of
information and knowledge – Biomedical Knowledge
– that can be employed in the generation of clinical
guidelines, protocols of care, and in the support of
evidence-based decisions.
Reference databases containing formal scientific and
technical literature are helpful in a research
environment but are of limited service in the day-to-
day practice of the non-academic environment. What
most clinicians require are fast, up-to-date, concise,
and structured responses to their queries that address,
in a systematic manner, the diagnosis, findings,
therapy, and prognosis of health conditions.
 3

Reference databases, in the other hand, are useful in

researching quality studies, detailing successes as well
as shortcomings of health interventions but are of
difficult and time-consuming utilization – searches
bring up a large number of references that are tricky to
sort and the generated references to the formal
biomedical literature are not fit to provide the
structured answers expected by practical physicians.
Randomized clinical trials and systematic reviews of
such trials provide the most robust, coherent, and
systematic evidence about the effectiveness of health
interventions. The Cochrane Collaboration Library
(16,17) is an attempt to remedy the inadequacies of
formal reference databases, current research findings,
informal clinical experience, and the expectations of
practitioners. It was established as part of an
international effort to facilitate the preparation,
maintenance, and dissemination of systematic reviews
of the effects of healthcare. It approaches the criteria
of an ideal tool for EBP (11).
Librarians play an important function in the spread
and support of EBP because of their role in identifying
and retrieving appropriate literature from a variety of
sources. Understanding how to index and search for
diagnosis, etiology, therapy, and prognosis for original
studies, systematic reviews, meta-analyses, and
development of clinical practice guidelines are an
essential set of skills that librarians can provide to
support clinicians (13).
The traditional search and retrieval methods used in
literature search, however, were found to be
inadequate and automated tools have been developed
to facilitate that process. Literature search software
applications (18) and special automated data
collection and content databases have been devised
(19,20) to help overcome the limitations of the
traditional bibliographic retrieval systems.

CLINICAL
BASIC
OBSERVATIONAL
RESEARCH
DATA

BIOMEDICAL
LITERATURE
CLINICAL
TRIALS &
REVIEWS
CURRENT
CLINICAL RESEARCH
DATABASES
UNENDORSED
SOURCES OF
HEALTH
INFORMATION

INDIVIDUAL
MEDICAL
RECORD BIOMEDICAL KNOWLEDGE
(EMR) GUIDELINES
DATABASE WEB-BASED
INTERACTIVE
HEALTH
INFORMATION

DECISION
SUPPORT
SOFTWARE
ADMINISTRATIVE
DATABASES CONTEXTUAL
INFORMATION
(ENVIRONMENT,
ANTHROPOLOGY,
EPIDEMIOLOGY,
SOCIO-ECONOMIC)

PATIENT
ENCOUNTERS EVIDENCE-BASED DECISIONS

Figure 1. The Spectrum of IS&T Support to Evidence-Based Practice

Contextual Data
Historically and pragmatically, two less controlled and
frequently non-validated sources of data and evidence
constitute the most frequent foundation for decision
making by practitioners:
• Contextual information, related to environmental,
socioeconomic, and epidemiological data for a
particular site and time, and
• The accumulated individual past encounters with
the healthcare system, present in the individual
medical record.
Contextual information is generally short lived,
limited in geographic scope, and not subject to the
rigorous systematic review process followed by
formal literature publications. The central issue here is
the fast availability of data that may be only valid to a
very specific site, but carrying an extremely high
informational value. An example being the diagnostic
support importance of the weekly reporting on the
incidence of communicable diseases.
The enhancement of data definitions and quality
controls in the processes of collection and processing
of morbidity and mortality data, and advances in the
reporting and communication of the incidence and
prevalence of communicable diseases and
environmental health risk factors, has ascertained the
importance of epidemiological and environmental
evidence in clinical decision-making. Most countries
have established mechanisms for fast access and
dissemination of such evidence and informatics and
telecommunications have played a central role in the
implementation of such mechanisms. Examples are
the U.S. Centers for Disease Control and Promotion
publications and the Internet sites and epidemiological
information dissemination centers maintained by
national, state, and municipal health authorities in
most countries.
Information systems dealing with contextual data and
information always played an important role in
making such type of evidence available to
practitioners. With the more recent developments in
telecommunications they gained renewed interest and
increased role. The emergence of Internet-based
contextual information will be examined in detail
latter.
Point-of-Care Data Capture and Data
Wharehousing: Clinical and Administrative Data
Repositories
In the manual non-automated medical and
administrative record paradigm, data fragmentation,
lack of structure, terminology incompatibilities, the
separation of clinical from financial and
administrative data, and episode fragmentation – the
breakup of patient data over time and geographic
space, all residing in different physical sites under
different patient identifiers – disallowed a systematic
utilization of the wealth of data residing in patient
records. Moreover, record integration at the individual
level requires a unique identifier and uniform clinical
encounter data sets and classification terminologies.
Such standardization is a necessary pre-requisite for
the upstream consolidation of individual patient
clinical and administrative data.
With the possibility of capturing data at the point of
care and the emergence of computer-based structured
health records (Electronic Medical Record), a whole
new spectrum of possibilities are opened to improve
access to individual and collective patient data
residing in data repositories, independently of the site
of care. Data related standards are a major issue in the
operationalization of the electronic medical record.
Inside a number of organizations most of the
standardization issues have been already addressed –
notable examples being the Kayser-Permanente and
the Mayo Clinic models of EMR. There is a mounting
effort to reach consensus at national and international
levels.
Data “warehousing” applications permits digital data
from various sources to be merged and accessed by
any authorized user and, when used in conjunction
with knowledge engineering techniques and products,
the digitalized clinical, administrative, and financial
data can be mined and exploited to support outcome-
based clinical processes and health interventions.
From a population perspective, collections of
structured records can be maintained in clinical and
administrative data repositories and selectively
extracted to assist in the construction of clinical
guidelines and evidence-based clinical and
administrative decisions processes. “Intelligent
agents” is a recent development in software
 5
technology that allow selective extraction of data from
large data repositories.
The use of clinical and administrative data repositories
is rapidly becoming a viable and affordable method of
supporting EBP, although there are a number of
problems to be solved, the most significant being: data
capture, consolidation, and reliability; standards; and
confidentiality issues.
Evidence-based decision making is also making
inroads in management and are rapidly gaining
acceptance in areas like purchasing, contracting, and
resource allocation taking advantage of cumulative
regional databases of past activities to support
administrative decisions. A number of support
informational tools have been developed to manage
human, material, and financial resources, product and
supplier selection, etc.
The privacy issue regarding access privileges and data
control is particularly serious – the transformation of
data residing in paper in different sites into integrated
digital data, easily retrieved through a variety of
access points, and the recovery of data about
individually identified persons, creates the possibility
of misuse. Although, many of the possible uses of
detailed patient data, such as population-based studies
of the efficacy of alternate care interventions, can be
done without individual source identification, a
variety of possible uses require patient identification.
On the other hand, the demands of many care-related
tasks such as reimbursement, composite individual
record, auditing for fraud and abuse, “push”
techniques in healthcare delivery, and support to
direct patient care require the ability to access patient-
specific data outside the care setting. From a technical
perspective alone, to merge patient data from diverse
sources requires the identification and transport of
patient-specific data with all the attendant privacy
issues that such process involve.
“Push” techniques, whereby health managers, using
patient-specific information identify candidates for
potential interventions and reach out health programs,
even though considered, in most circumstances,
justifiable from the preventative public health and
health promotion standpoint, can trigger strong
opposition. In this regard, consider the controversy
generated in the U.S. when several chain pharmacies
disclosed patient-specific data to third parties (21).
Clinical Decision Support Software
Clinical decision software applications are designed to
support the analysis of patient data and to automate
aspects of clinical decision making that can be
expressed as rules. Such rules can be built and
maintained by a database of guidelines and the
implications of the mainstream introduction and use of
clinical decision-support software are many and far-
reaching. Concerns raised involve questions such as:
• When the amount of automated “clinical thinking”
done by the software application constitutes
“practice of medicine” with all its associated
ethical and legal aspects?
• Is it to be considered a medical device passive of
regulation?
• To what extent does the application software
allows clinicians to examine the underlying logic
and to independently evaluate how the software
arrived at particular conclusions?
• What is the role of such products in critical
clinical decisions?
• How the consequences of eventual errors are to be
dealt with?
It has been pointed out that there is a vast array of
problems that have not yet been addressed. The issues
are important in light of the fact that the health
information technology industry is investing millions
of dollars in developing such applications.
Developments on a number of policy, legislation, and
regulation issues are badly needed in this area (22).
Internet-based Interactive Health Information
Advances in telecommunications, computer
applications, and user interfaces are changing the
nature of interactions between health professionals
and the population and the Internet (World Wide
 6
Web), a low cost, ubiquitous, and flexible technology,
is the fastest growing medium in history.
The growing area of Interactive Health
Communication (IHC) is defined as (23): “ the
interaction of an individual, consumer, patient,
caregiver, or professional, with or through and
electronic device or communication technology to
access or transmit health information or to receive
guidance and support on a health-related issue.” The
impact of these technologies are found in the relay of
data and information, in enabling informed decision
making, in the promotion of healthy behaviors, in the
facilitation of peer information exchange, self-care,
and in the management of the demand for health
services.
IHC applications are changing the nature of health
communications and health practice, they are
accelerating the empowerment of providers and
patients, and making easier for consolidated entities to
operate within increasingly large and complex
organizations. “Old” media, including radio,
television and print have effectively contributed to
knowledge dissemination and health promotion – the
new opportunities offered by Internet-based IHC have
the following characteristics (23):
• Increased access to health information and support
on demand in any site via a plain telephone line or
any variety of wireless communication options.
• Increased opportunity for interactions among
users using electronic messaging.
• Enhanced ability for widespread dissemination
and for keeping contents and functions current.
• Improved opportunity to tailor information to the
specific needs of individuals or user groups.
• Multimedia resources, combining text, audio and
visuals.
• Increased opportunity for users to remain
anonymous, thus facilitating access to sensitive
information and frank discussions about health
status, behavioral risks, and fears and
uncertainties.
The main health-related concern of the widespread use
of interactive Web-based technologies is the
enormous volume of unendorsed, nonvalidated,
misleading, and potentially harmful health
information available on the Internet (24). Clearly,
there is enormous interest of the general population in
retrieving health information – according to one
study, of the approximate 50 million Internet adult
users in the U.S., over 17 million searched the Internet
for health information for the year ending July 1998,
and this number is estimated to double in the next two
years (25).
IS&T and Knowledge Management
Challenges
How to approach the utilization of clinical and
management health information is still a complex,
chaotic, and controversial subject. It is not surprising
that many expectations regarding the contribution of
health information systems to clinical practice have
not been fulfilled.
The history of failures to deliver products
that are acceptable to practitioners, the
difficulties of automating clinical
decision-making processes, the industry
failure to appreciate the peculiar
economics and culture of healthcare
delivery systems, the nagging lack of
policies, and the improperly understood
and incompletely addressed information
systems technological issues, consist the
core problems of most experiences with
health information systems development
and implementation.
Patient medical records and encounter data as source
of evidence data requires the redesign of clinical
records, methods to capture and organize data,
computerization of records, methods for data search,
and data interpretation. Many investigators have
attempted to extract meaningful data out of textual
material recorded in clinical encounters, but the
handling of medical record text is fraught with serious
difficulties because of the idiosyncrasies of medical
records. An example is HEALNet, a project directed
at information extraction from medical text in support
of EBP using statistical concept representation and the
 7
construction of a core information retrieval engine
(26).
Although information technology has the potential to
dramatically sharpen the focus of the healthcare
systems on patients’ needs and preferences, this will
only be reached by a concerted effort by professionals,
governments and the industry to address the above
problems (27,28).
The great majority of innovative developments in
informatics products for the health sector and their
implementation will arise from the motive for profit.
While the private sector is promoting the rapid
development of new health information technologies,
the public sector has been mostly passive and may
even create roadblocks, intentionally or otherwise, to
the spread of technology. In special, privacy concerns,
software regulatory policies, and ethical and legal
issues regarding telehealth may be the source of
conflicts in the near future [21].
The dissemination of guidelines present special
problems. Segmentation of the target audience is
necessary for effective dissemination of guidelines, a
study in the Netherlands conducted among family
physicians to evaluate the adoption of evidence-based
practice guidelines indicated that for some
practitioners it is desirable to make evidence quickly
available through publications, for other spreading the
guidelines through local networks was found
effective, while for another group a more active,
personal approach was found to be necessary [29].
It has been suggested that the most important
transformation needed today in the teaching of
medicine is to foster the information management
aptitude of future professionals. Training has been
considered a major component in the implementation
of EBP. Evidence-based medicine is an increasingly
important concept in medical school curricula and
continuing medical education [7].
Getting evidence into practice requires resources and
organization [30,31,32] and to use evidence-based
decision-making requires organizations that have
systems for finding and appraising evidence and
professionals who are skilled in searching, evaluating,
storing, and using information and knowledge.
Besides the need for economic and organizational
discipline, true healthcare reform will require a health
information revolution. A key symptom of the
absence of rationalization in the sector is the virtual
lack of systematic and uniform operations-
measurement techniques and tools and quality and
control data, which were not required under the public
cost-plus or private fee-for-service models of care.
Health reform “industrialization” processes involve
statistical process control, operations research and
reengineering techniques, line-employee (direct care
provider) performance measurement, benchmarking,
and outcomes measurement. New techniques include
program budgeting and marginal analysis studies, an
economic evaluation combining practice data for the
before period and literature data to model the after
period [33]. These initiatives require vast quantities of
healthcare data and a wealth of data processing and
analytical intelligence. The ultimate goal of healthcare
industrialization is to provide every clinical situation,
no matter how unique, with automated digital support
that will generate quantitative predictors, optimized
decision-making, and maximized results, be they
lower costs, improved quality, or a combination of
both.
The computerized applications to support such
objectives must follow a hierarchy in which systems
tasks range in complexity from reference retrieval and
the processing of transactions to more complex
decision-support systems. The functions required by
EBP in management and clinical service delivery
involves both ends of the spectrum. They include
static and dynamic modeling routines, driven by rules,
normative knowledge databases, and vast stores of
clinical and administrative data. Their outputs consist
of quantitative comparisons of outcomes associated
with alternative managerial and medical decisions.
Those factors are major challenges for medical
informatics and argue for significant public
investments in technology development through
collaborative research efforts among the industry,
academic centers, research centers, the health
establishment, and the government.
 8
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