Professionals and patients need clean clear knowledge for decision making just as they need clean clear water for hand washing

Water may look clear but be polluted and poisonous

At present people simply hold out a basin to collect knowledge, or

dip a bucket in the sea of PubMed, one of the wonders of

modern healthcare but peer review is no guarantee of

freedom from pollutants - bias and errors due to chance- or

poison due to the deficiencies of the peer review and editorial

process

3 types of generalisable knowledge

Knowledge from research - Evidence

Knowledge from measurement of healthcare performance-Statistics

Knowledge from experience-Of patients and clinicians

2 types of particular knowledgeKnowledge about this patient

Knowledge about this service

Better decisions

Finding out what knowledge people need

Obtaining the knowledge

Organising the knowledge

Mobilising the knowledge

Utilising the knowledge

NLH 2011

NLH

CONTENT 2011

Protocols for systematic reviews or additional research

Reports of research

Systematic reviews of research

Guidelines informed by systematic reviews

Summaries of knowledge eg BNF

Information about uncertainties eg DUETs

Patient Experience Reports

Tools for diagnosis, treatment & monitoring

Prompts & reminders

BETTER DECISIONS&

ACTIONS

‘Conclusions in trials funded by for profit organisations may be more

positive due to biased interpretation of trial results’

The experimental drug was recommended as treatment of choice in16% of trials funded by nonpofit organisations51% of trials funded by for-profit organisations (p<0.001)Trials funded by for-profit organisations were significantly more likely to recommend the experimental drug as the treatment of choice – odds ratio 5.3 (CI 2.0-14.4)

Association of funding and conclusions in randomised drug trialsAls-Nielsen B et al (2003) JAMA 290; 921-928

“evidence from recent trials, no matter how impressive, should be interpreted

with caution”claims for efficacy made in 45 highly

cited citations were subsequently contradicted or weakened for 14 of

the interventionsIonnidis JPA (2005)

Contradicted and initially stronger effects in highly cited clinical research

JAMA 294; 218-228

NLH

SERVICES 2011

All serious health problems are managed by more than

one bureaucracy and always will be.

They are managed by clinical networks which cross many

bureaucracies.

Shared Vision

Hypertext organisation Bureaucratic Organisation(Nonaka & Takeuchi OUP 1995 ; The Knowledge Creating Company

The National IBD Service

A National IBD Service would have A National set of objectives, criteria and

standards A nationally agreed templates of a care pathways

expressed using the Map of MedicineA National DatasetA single specification for all information system providersA National knowledge base updated annually

A National community of practice, including patientsA single web site www.nhs.uk/ibd

X local services, where X is >1 and <150

NLH

READERS 2011

Patient centred care

• The Clinician was the driving force in the 20th Century , the patient will be the driving force in the 21st century

Most patients in 2011 •Feel responsible for their own record •Know their NHS number•Read and think about the quality assured knowledge sent to them before the consultation•Enter their own data before the consultation•Use a decision aid before taking the decision to have an operation •Know where they are on a care pathway•Accept that medical knowledge is of variable quality

Muir Gray has familial hypercholesterolaemia

Every six months he receives an email reminder from the lab to have a blood test

He receives 2 SMS reminders if no blood sample is received within 2 weeks

If no specimen is received his GP receives a copy email

If there is a result is sent to the GP and to his Healthspace where it is stored in sequence

Appropriate advice and support is automatically generated

Mrs A is worried about familial breast cancer and phones for a GP appointment

The healthcare assistant asks if Mrs A would like to tell her the nature of her problem

On learning it, she

1. Ascertains her access to NHS Direct

2. identifies the relevant page on NHS Direct

3. Sends it to Mrs A

Mrs A consults the site which1. Ascertains her preferred reading level 2. Ascertains her knowledge of genetics eg the meaning of the term mutation3. Offers information about genetics and familial breast cancer including the experience of other women in DIPEX4.Allows her to complete a family risk assessment5. Stores all this information on her Healthspace

20th century

Knowledge Clinician Patient

21st century

Knowledge Clinician Patient

Knowledge Clinician Patient

www

Seeksadvice

Offers reflection

HEALTHY CHOICES WILL BE EVERYWHERE

NLH

KNOWLEDGE DELIVERY 2011

Phased in National Knowledge WeeksFocussed through My LibraryActive

Guidance in long esoteric documents can be embedded

in lab request and report forms

“The false positive rate [for Hepatitis C] is especially

important in low prevalence settings where the number of false positives may exceed

the number of true positives”Booth JCL et al (2001)

Gut 49 (Suppl 1) i4 column 1 Section 3.1 lines 23-27

What it really looks like

Royal Cornwall Lab Service

Muir Gray 21/06/1944 NHS number 400 186 6897

ELISA25.5

Hepatitis C is of low prevalence in Cornwall. National guidance is that diagnosis should be confirmed by PCR test in low prevalence populationsFor PCR test click here

For access to full text of guidance click here To test your knowledge in one minute click here

NLH

LIBRARIANS 2011

1,275 librarians

Image from Sinasis Technologies via free clip art service http://www.artvex.com

“It is not the strongest of the species that survives, nor

the most intelligent that survives. It is the one that

is the most adaptable to change.”

Ignorance is like cholera; it cannot be controlled by the individual alone it requires the organised efforts of society