EXHIBIT 1. Profiles Of Scenarios Involving The Electronic Health Record (EHR).

Scenario	Dominant application	Example	Strengths/advantages	Disadvantages
Facilitating RCTs in practice	Traditional practice-based RCTs	Large multicenter clinical trials	Acceleration of RCT timeline, understanding of selection bias	Favor EHR adopters
Retrospective analysis of EHR data	Retrospective analysis of typical clinical interventions that have been in use for several years; etiology, diagnosis, and prognosis studies	Evaluate effectiveness of different treatments and combinations of treatment for the management of hypertension	Highly relevant to clinical practice: offers the only means for comparative treatment analysis for the same outcome	Measurement error, bias, confounding, confounding by indication, and completeness of data
Testing of self-sustaining health services models	Use of patient-completed questionnaires, systematic use of behavioral health interventions, patient self-management training, systematic adherence to care per guidelines	For example, like the 1960s HIP study of mammography: introducing a new diagnostic by varying eligibilitya	Testing of new models of care must fit the workflow of clinical practice; if the model improves outcomes and is successful, then the “translation to practice” challenge is simultaneously addressed and solved	Requires a strong alignment of the research, IT, and practice groups
Real-time use of decision support and all patient data in practice	In everyday practice to directly integrate CPGs and other codified knowledge with practice decisions and to make use of data on other patients as needed to tailor treatment for a particular patient	What is the best medication to add to an already complex regimen for a patient with multiple comorbidities and insurance restrictions on treatment options?	Provides clinical guidance in complex situations; directly provides the physician with knowledge as needed; makes effective use of longitudinal data on other patients	Limits to knowledge and the above methodological limits to use of retrospective data
Randomizing uncertainty in real time	Clinical decision making in situations of equipoise	What is the real-world NNT for various statins?	Simple to do and replicate in numerous settings	Generalizability might be overestimated if relying on one population

SOURCE: Derived from the authors’ own work.

NOTES: RCT is randomized controlled trial. IT is information technology. CPG is clinical practice guideline. NNT is number needed to treat.

^aSee S. Shapiro et al., “Current Results of the Breast Cancer Screening Randomized Trial: The Health Insurance Plan (HIP) of Greater New York Study,” in Screening for Breast Cancer, ed. N.E. Day and A.B. Miller (Toronto: Hans Huber, 1988), 3-15.