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PROLOGUEImplementing EvidencePROLOGUE: No medical research helps patients if clinicians do not adopt the practices supported by evidence. As Carolyn Clancy, director of the Agency for Healthcare Research and Quality (AHRQ), notes in the following section, research has undergone explosive growth, and yet there is a seventeen-year delay between evidence and clinical practice. In spite of developing research, medical practice in many cases remains the province of clinical experience and judgment that is not always supported by the available science. How best to implement the practices that improve the quality of health care is the topic of the three papers here. In the first paper, Kaveh Shojania and Jeremy Grimshaw, of the University of Ottawa and the Ottawa Health Research Institute, drill into an area even less well understood than evidence-based medicine: evidence-based methods for intervening to promote evidence-based medical practice. Shojania and Grimshaw describe the evolution of quality improvement (QI) implementation and research into it, as well as the barriers to QI interventions, the problems with designing the research, and the difficulty in deriving useful results. They conclude by cautioning that the medical community often "expects miracle cures" in quality improvement, much as patients expect wonder drugs that will treat their diseases, even though in medical quality, "progress occurs through incremental gains." Next, Clancy and Kelly Cronin, a senior adviser in the Office of the National Coordinator for Health Information Technology in the U.S. Department of Health and Human Services, recognize the value of evidence-based practice in reducing variations in the rate of health care services, as well as reducing inappropriate services and helping control costs. Information technology (IT) has the ability to put the latest science into the hands of clinicians, as well as patients, to help them make difficult choices, but the point is not "limiting options or replacing clinical judgment." To Clancy and Cronin, evidence-based medicine will work best when decisions are made at the local level, informed by the global evidence. Finally, Sandra Tanenbaum, of the Ohio State University School of Public Health, describes the controversies of evidence-based practice in mental health care. The mental health care field has yet to decide definitively what evidence is, whether to apply evidence-based practice indiscriminately without applying case-by-case judgment, and what effective treatment is. However, managed mental health care plans and policymakers are promoting evidence-based practice without resolution of those controversies, which elevates the danger of ineffective and limited care. Alan Garber of Stanford University offers a perspective on these papers, as does Sean Tunis of the Centers for Medicare and Medicaid Services.
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