Evaluation of PICO as a knowledge representation for clinical questions

The paradigm of evidence-based medicine (EBM) recommends that physicians formulate clinical questions in terms of the problem/population, intervention, comparison, and outcome. Together, these elements comprise a PICO frame. Although this framework was developed to facilitate the formulation of clinical queries, the ability of PICO structures to represent physicians' information needs has not been empirically investigated. This paper evaluates the adequacy and suitability of PICO frames as a knowledge representation by analyzing 59 real-world primary-care clinical questions. We discovered that only two questions in our corpus contain all four PICO elements, and that 37% of questions contain both intervention and outcome. Our study reveals prevalent structural patterns for the four types of clinical questions: therapy, diagnosis, prognosis, and etiology. We found that the PICO framework is primarily centered on therapy questions, and is less suitable for representing other types of clinical information needs. Challenges in mapping natural language questions into PICO structures are also discussed. Although we point out limitations of the PICO framework, our work as a whole reaffirms its value as a tool to assist physicians practicing EBM.