Key Driver 1: Seek, Select, and Customize the Best Evidence for Use by the Practice

The practice of medicine evolves in response to new knowledge about what care produces the best outcomes for patients and how best to deliver that care. Because of their commitment to delivering the best possible care, both solo practices and large groups will want to have a plan for identifying and selecting evidence, recommendations, and guidelines that are important enough to merit practice-wide adoption. Once the practice agrees to implement new evidence, it often must customize it to the practice environment. This does not mean that evidence-based care is a cookbook to be followed unwaveringly. Care must be tailored to meet the needs, circumstances, and preferences of individual patients, and practice teams may find different ways to approach the delivery of evidence-based care. Translation of evidence into practice-wide protocols, however, allows care team members to create expectations of each other and use clinical information systems to ensure the right care is provided to the right patient at the right time. Practices should proudly inform their patients that the care they provide is evidence-based.

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Change Strategies

Develop a process to search regularly for new evidence
The medical literature is large and new research findings are published continually. Primary care clinicians usually have their own individual processes for staying up-to-date. Nonetheless, the practice should have a process in place to ensure that the practice as a whole is aware of important new syntheses of evidence and high-quality evidence-based guidelines. Not all recommendations and guidelines are equally useful. Some rely less on evidence and more on expert opinion and others are biased by the perspective of the organization creating them. In addition to being aware of new robust clinical evidence, practices should also be on the lookout for evidence on how to organize and deliver care. As well as encouraging all clinicians to share evidence updates with the practice, practices should designate one or more team members to be responsible for consulting trusted sources of evidence on a regular basis, such as monthly or quarterly.

Embed selected evidence and guidelines into clinical information systems
Research shows that relying on individual clinicians to recognize all of a patient’s needs and remember all recommendations leads to gaps in care. Functional clinical information systems can make it easier for teams to adhere to agreed-upon actions to implement evidence. For example, electronic information systems (e.g., electronic health records, registries) can identify which evidence-based recommendations apply to a given patient and provide teams with standing orders that allow each team member to complete their designated tasks. Non-electronic information systems, including paper templates, checklists, and written scripts for front office staff and medical assistants, can also keep the integration of evidence into usual care on track. Embedding processes into information systems decreases the chance that any steps will be skipped, has the potential to reduce the tracking burden on the care team, and can make the computation of quality measures easier. (Go to Key Driver 3: Optimize information systems to extract data and support use of evidence in practice.)

Inform patients and families about the evidence the practice uses and its implications
Practices should communicate to their patients that the practice pays attention to evidence, and why this matters. This general message, which can be communicated via the practice’s website, bulletin boards, patient portals, and brochures, lays the groundwork for explaining specific evidence-based recommendations, such as why to get a flu shot or to stop smoking. Practices benefit when patients and families know that when clinicians make recommendations for care, they are based on research findings showing that patients who follow the recommendations usually have better health outcomes. (Go to Key Driver 5: Engage patients and families in evidence-based care and quality improvement for more on clinician-provider conversations and shared decision-making.)

Select and customize evidence for practice-wide implementation
Practices will need to prioritize which types of evidence they will implement practice-wide. It is critical that clinicians discuss and agree on the value of a body of clinical evidence before they attempt to implement it. Clinical evidence may be chosen based on what: is important to and has the greatest impact on their patients, is not already the standard of care for the practice, and is aligned with other practice goals and initiatives. In addition, practices may select organizational evidence (e.g., use of standing orders, expanded role for medical assistants) based on its ability to affect efficiency, job satisfaction, and external requirements. All team members should participate in the customization of evidence to the practice, such as deciding how to incorporate recommendations into practice workflow, developing educational materials, and selecting appropriate quality improvement measures. Agreeing on an approach to implementation paves the way for shared expectations of how different members of the practice support various steps in the implementation process. This does not mean that everyone in the practice has to execute protocols in exactly the same way. The evidence may support multiple pathways. But a degree of consistency across the practice is desirable, for example, so that clinical information systems can support newly established processes.

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