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The 5As of the Health Information Cycle: Robert Hayward, MD, defines the 5As of the health information cycle and helps learners understand the process.
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The 5As of the Health Information Cycle: Robert Hayward, MD, defines the 5As of the health information cycle and helps learners understand the process.
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>> I'm Joan Stephenson, editor of JAMA's Medical News and Perspectives section. Today, I have the pleasure of speaking with Dr. Rob Hayward. Dr. Hayward, why don't you introduce yourself to our listeners? >> Well, hi, Joan! It's a distinct pleasure chatting with you today. I do wear lots of different hats as it concerns evidence-based practice, but I am a contributing editor for the Users' Guides in JAMAevidence. And on the advisory board at my home institution at the University of Alberta I serve as Assistant Dean of Health Informatics, and I direct the Center for Health Evidence, which has had a long and very happy and productive affiliation with the User's Guides Initiative.
>> Dr. Hayward, would you describe the five steps of the Health Information Cycle, also known as the five As, and how can learners use the five As, on JAMAevidence.com? >> Well, I remember, in my teaching my faculty career, how sobering I found it to really believe in the fundamental importance of this approach to clinical decision-making and problem solving that we call evidence-based medicine; and yet, to find it so very difficult to apply in the hectic, busy circumstances of an internal medicine ward, for example.
And so it was more to make myself more honest that I found it necessary, working with so many other great thinkers in this area, to try and come up with some ways to express evidence-based medicine through its genuine simplicity. We can become intimidated by the call to evaluate research studies and find all their little flaws. And frankly, some of the methodologic considerations can be a bit tough to remember. But what's really exciting is when you get a group of clinicians together in a room, perhaps around a journal club or perhaps they're developing what we call a critically appraised topic, and we look at some research, and we just talk about it.
And then you realize that the core principles of evidence-based decision making are really variations on common sense, when it comes right down to it. And so the challenge in teaching about and promoting evidence-based decision making is finding where the simplicity is. So one example of that is that it's all about validity, importance, and applicability. But the other thing that we've come to realize as we've been teaching this over the years, is that the hardest thing to teach is how to get the question right and how to figure out which issues merit a search for high-quality external evidence and what kinds of issues are more matters of ethics or values and require a different kinds of knowledge or way of thinking.
And that's really where the information cycle came from. We wanted to have something that would be easy to remember, that would highlight how important the process of thinking is to evidence-based practice, and would emphasize those early stages that if you don't get it right, then no amount of forging around in the medical literature will help you out. So what do I mean? Well, the five As of the evidence-based information cycle are assess, ask, acquire, appraise, and apply.
What we mean by that is that initially, when confronted by a clinical scenario, something that you're a bit uncertain about or you're worried about with a patient, you need to reflect for a little bit, because within that anxiety about the patient's circumstance will be not one but usually many issues. And you need to learn how to prioritize, to pick those issues that can be resolved or you can get more clarity by going out and looking at evidence, what's been learned about other similar patients.
And so the assessed stage is about figuring out what the issues are, prioritizing them, and then classifying them. Is this issue a matter of treatment? Is it a matter of whether the treatment is going to hurt my patient? Is it a matter about what's going to happen in the future prognosis? Or is it a matter about whether I want to implement a clinical policy, practice guidelines? Knowing what the category of the issue is then leads us into the next stage, asking, because there are different actual structures, or formats, of well-built questions for different ways of knowing.
The question that I would ask about a question of therapy will be laid out differently than a question that I will ask about the experience of patients or the phenomena of healthcare. So a lot of what is found in the Users' Guides and JAMAevidence helps us with tools and aids and clinical scenarios to get that asking part right. We find if we can improve our learners' ability to ask questions, the rest is relatively straightforward. The next stage is given different types of questions, where do you go to get the evidence?
How do you acquire the evidence? And frankly, for qualitative questions, you really should go to some different places than you would for a pure therapy type question. Once you've gathered some evidence, ideally you will have able to work in a collection, or resource, where someone else has done a good job at appraising that evidence for its validity, importance, and applicability. And your ability to recognize that they've done that will help you to decide whether you can use the information.
So the appraising stage doesn't necessarily mean doing a critical appraisal yourself. Often it means being able to detect when someone else has a good process and has summarized the information for you nicely. And then, finally, at the apply stage, and that's not really something that you can every really read about. You need experience in learning when and how to apply evidence to individual patient circumstances to get the best possible result that they would care about.
So in sum then, we assess, we ask, we acquire, we appraise, and we apply, and all five steps are equally important to being an evidence-based decision maker. >> How can learners use these five As on JAMAevidence.com? >> Well, one of the things that all of us are excited about with JAMAevidence is that we're now into a full second edition of the Users' Guides and a redo of the Rational Clinical Exam. And a great deal of thinking has gone into how to organize the material online and make it easier to serve the information cycle.
And that has enabled us, facilitated with things like worksheets that emphasize those core principles and the steps that you need to go through when trying to think through a question or a problem or to evaluate any journal article that you've found. There are also wizards, we call them, or tools that can help you destruct your questions in a way that works best for the different kinds of issues that you're trying to address. And there's multiple ways to experience the Users' Guides online.
One can experience them pretty much like you would the book itself, but you also have ways to come into the information, through the stages of the information cycle, if that's what you need. Folks can sometimes be intimidated by the information cycle, because we seem to imply that every physician at all times with all patients should be mentally ticking off the five As. Well, that's not the case at all. A lot of what we do in day-to-day practice is very routine for us. I'm a general internist, and there's certain healthcare problems that are my bread and butter.
I know them inside out, and so I don't spend a lot of time on assessing or asking, but I do know that the knowledge for the problems I deal with is more or less volatile. And I make a commitment, a contract with myself, to re-examine that evidence periodically. But every day, I get stumped. I get some patient who comes in with some truly extraordinary or unusual or something that is usual but with a new twist, and then I do find that I invest time in the assess and the ask or the appraise stage of the information cycle.
So there, too, the Users' Guides are a big help to me because they're now organized in a way in which I can say, you know, it's really about the asking questions that I need a little bit of help here, and I don't want to read a whole book for that. So the online makes it really easy for you to jump at the bit that you need for the routine or the complex problems that you're trying to sort out. >> What resources on the JAMAevidence website do you think will be most helpful for learners? >> Well, I think that question can only be answered by reference to the different kinds of learners that are out there.
If I was answering that with a medical student in mind, I would emphasize the core sections at the very beginning, the early sections of the Users' Guides, which focus on the nature of evidence-based thinking, how to ask questions, and the basics about where to find evidence that pertains to different classes of questions. I would really emphasize doing one or two of the core sections on things like questions of therapy or systematic reviews or practice guidelines.
And from that, one gets a sense of the style, the approach to problem solving that is evidence based. After that, I'd probably suggest that for folks that are fairly new to this, they jump right into things like the information cycles, the critical appraisal worksheets, or things like the online calculators and the question building with it. The calculators, for example, really emphasize the experiential learning. If you're trying to figure out what a likelihood ratio means and why you should be aware of it in clinical practice, and you're a medical student and you're new to this, I'd suggest get in there and play with one of the interactive calculators, because that gives you a feel for how pretest probabilities, the likelihood that someone has a problem, affect the likelihood that they have a problem after you've done a test.
It's hard to get a sense of that if you read about it or try and understand a formula, but if we play with a calculator, it's much easier to get a feel. So I emphasize some of the extra things that are part of the online resource that you simply can't get in the book, interactive calculators, worksheets that help you take a paper you're reading, answer some basic questions, and have more of a sense of its believability, and things like the information cycles attached to many of the chapters. >> Thank you very much, Dr. Hayward.
>> Thank you.
Segment:0 .
>> I'm Joan Stephenson, editor of JAMA's Medical News and Perspectives section. Today, I have the pleasure of speaking with Dr. Rob Hayward. Dr. Hayward, why don't you introduce yourself to our listeners? >> Well, hi, Joan! It's a distinct pleasure chatting with you today. I do wear lots of different hats as it concerns evidence-based practice, but I am a contributing editor for the Users' Guides in JAMAevidence. And on the advisory board at my home institution at the University of Alberta I serve as Assistant Dean of Health Informatics, and I direct the Center for Health Evidence, which has had a long and very happy and productive affiliation with the User's Guides Initiative.
>> Dr. Hayward, would you describe the five steps of the Health Information Cycle, also known as the five As, and how can learners use the five As, on JAMAevidence.com? >> Well, I remember, in my teaching my faculty career, how sobering I found it to really believe in the fundamental importance of this approach to clinical decision-making and problem solving that we call evidence-based medicine; and yet, to find it so very difficult to apply in the hectic, busy circumstances of an internal medicine ward, for example.
And so it was more to make myself more honest that I found it necessary, working with so many other great thinkers in this area, to try and come up with some ways to express evidence-based medicine through its genuine simplicity. We can become intimidated by the call to evaluate research studies and find all their little flaws. And frankly, some of the methodologic considerations can be a bit tough to remember. But what's really exciting is when you get a group of clinicians together in a room, perhaps around a journal club or perhaps they're developing what we call a critically appraised topic, and we look at some research, and we just talk about it.
And then you realize that the core principles of evidence-based decision making are really variations on common sense, when it comes right down to it. And so the challenge in teaching about and promoting evidence-based decision making is finding where the simplicity is. So one example of that is that it's all about validity, importance, and applicability. But the other thing that we've come to realize as we've been teaching this over the years, is that the hardest thing to teach is how to get the question right and how to figure out which issues merit a search for high-quality external evidence and what kinds of issues are more matters of ethics or values and require a different kinds of knowledge or way of thinking.
And that's really where the information cycle came from. We wanted to have something that would be easy to remember, that would highlight how important the process of thinking is to evidence-based practice, and would emphasize those early stages that if you don't get it right, then no amount of forging around in the medical literature will help you out. So what do I mean? Well, the five As of the evidence-based information cycle are assess, ask, acquire, appraise, and apply.
What we mean by that is that initially, when confronted by a clinical scenario, something that you're a bit uncertain about or you're worried about with a patient, you need to reflect for a little bit, because within that anxiety about the patient's circumstance will be not one but usually many issues. And you need to learn how to prioritize, to pick those issues that can be resolved or you can get more clarity by going out and looking at evidence, what's been learned about other similar patients.
And so the assessed stage is about figuring out what the issues are, prioritizing them, and then classifying them. Is this issue a matter of treatment? Is it a matter of whether the treatment is going to hurt my patient? Is it a matter about what's going to happen in the future prognosis? Or is it a matter about whether I want to implement a clinical policy, practice guidelines? Knowing what the category of the issue is then leads us into the next stage, asking, because there are different actual structures, or formats, of well-built questions for different ways of knowing.
The question that I would ask about a question of therapy will be laid out differently than a question that I will ask about the experience of patients or the phenomena of healthcare. So a lot of what is found in the Users' Guides and JAMAevidence helps us with tools and aids and clinical scenarios to get that asking part right. We find if we can improve our learners' ability to ask questions, the rest is relatively straightforward. The next stage is given different types of questions, where do you go to get the evidence?
How do you acquire the evidence? And frankly, for qualitative questions, you really should go to some different places than you would for a pure therapy type question. Once you've gathered some evidence, ideally you will have able to work in a collection, or resource, where someone else has done a good job at appraising that evidence for its validity, importance, and applicability. And your ability to recognize that they've done that will help you to decide whether you can use the information.
So the appraising stage doesn't necessarily mean doing a critical appraisal yourself. Often it means being able to detect when someone else has a good process and has summarized the information for you nicely. And then, finally, at the apply stage, and that's not really something that you can every really read about. You need experience in learning when and how to apply evidence to individual patient circumstances to get the best possible result that they would care about.
So in sum then, we assess, we ask, we acquire, we appraise, and we apply, and all five steps are equally important to being an evidence-based decision maker. >> How can learners use these five As on JAMAevidence.com? >> Well, one of the things that all of us are excited about with JAMAevidence is that we're now into a full second edition of the Users' Guides and a redo of the Rational Clinical Exam. And a great deal of thinking has gone into how to organize the material online and make it easier to serve the information cycle.
And that has enabled us, facilitated with things like worksheets that emphasize those core principles and the steps that you need to go through when trying to think through a question or a problem or to evaluate any journal article that you've found. There are also wizards, we call them, or tools that can help you destruct your questions in a way that works best for the different kinds of issues that you're trying to address. And there's multiple ways to experience the Users' Guides online.
One can experience them pretty much like you would the book itself, but you also have ways to come into the information, through the stages of the information cycle, if that's what you need. Folks can sometimes be intimidated by the information cycle, because we seem to imply that every physician at all times with all patients should be mentally ticking off the five As. Well, that's not the case at all. A lot of what we do in day-to-day practice is very routine for us. I'm a general internist, and there's certain healthcare problems that are my bread and butter.
I know them inside out, and so I don't spend a lot of time on assessing or asking, but I do know that the knowledge for the problems I deal with is more or less volatile. And I make a commitment, a contract with myself, to re-examine that evidence periodically. But every day, I get stumped. I get some patient who comes in with some truly extraordinary or unusual or something that is usual but with a new twist, and then I do find that I invest time in the assess and the ask or the appraise stage of the information cycle.
So there, too, the Users' Guides are a big help to me because they're now organized in a way in which I can say, you know, it's really about the asking questions that I need a little bit of help here, and I don't want to read a whole book for that. So the online makes it really easy for you to jump at the bit that you need for the routine or the complex problems that you're trying to sort out. >> What resources on the JAMAevidence website do you think will be most helpful for learners? >> Well, I think that question can only be answered by reference to the different kinds of learners that are out there.
If I was answering that with a medical student in mind, I would emphasize the core sections at the very beginning, the early sections of the Users' Guides, which focus on the nature of evidence-based thinking, how to ask questions, and the basics about where to find evidence that pertains to different classes of questions. I would really emphasize doing one or two of the core sections on things like questions of therapy or systematic reviews or practice guidelines.
And from that, one gets a sense of the style, the approach to problem solving that is evidence based. After that, I'd probably suggest that for folks that are fairly new to this, they jump right into things like the information cycles, the critical appraisal worksheets, or things like the online calculators and the question building with it. The calculators, for example, really emphasize the experiential learning. If you're trying to figure out what a likelihood ratio means and why you should be aware of it in clinical practice, and you're a medical student and you're new to this, I'd suggest get in there and play with one of the interactive calculators, because that gives you a feel for how pretest probabilities, the likelihood that someone has a problem, affect the likelihood that they have a problem after you've done a test.
It's hard to get a sense of that if you read about it or try and understand a formula, but if we play with a calculator, it's much easier to get a feel. So I emphasize some of the extra things that are part of the online resource that you simply can't get in the book, interactive calculators, worksheets that help you take a paper you're reading, answer some basic questions, and have more of a sense of its believability, and things like the information cycles attached to many of the chapters. >> Thank you very much, Dr. Hayward.
>> Thank you.
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