Orakle.

Point of care education · Accredited CME · Case-based learning · Webinars · Risk scores

Ten years of
content creation

Orakle is a medical publisher and education provider. We build novel solutions to problems in medicine: case simulations, decision aids and risk scores, made with the societies, faculty and patient associations who own the evidence.

Innovation rarely fails for lack of evidence. It fails on the last metre, between the publication and the consultation. That metre is our whole business.

Expert’s Corner

Accredited case-based learning, webinars and podcasts, written with specialty faculty across four programmes. Education built to change the next consultation.

DxTx

Validated risk scores, nomograms and shared decision making tools, serving health professionals worldwide, built for use inside the consultation.

How we work

Built with the evidence, and its pioneers.

Evidence moves slowly into practice, and the reasons are rarely scientific. For ten years we have built the missing piece — the programme, the decision aid, the score — with the people who wrote the evidence in the first place.

Every output remains yours to interpret.

The evidence test

What the literature actually says.

Eleven questions from Cochrane reviews, meta-analyses and landmark trials, about what actually moves evidence into practice: the education clinicians finish, and the decision rules they trust. The findings are rarely the ones any of us would predict in advance.

Choose an answer. The evidence and citation appear immediately.

  1. 01 / 11

    A 2021 Cochrane review pooled 65 comparisons (7,868 health professionals) of continuing-education meetings and workshops against no intervention, measuring compliance with desired clinical practice. What did it find?

    Correct

    Not quite — the answer is B

    Across 65 comparisons, educational meetings as the main component of an intervention were associated with an adjusted risk difference of 6.79% (95% CI 6.62 to 6.97) in compliance with desired practice, and across 15 comparisons a 3.30% improvement in patient outcomes (95% CI 3.10 to 3.51), both rated moderate-certainty. The authors' conclusion: educational meetings "probably slightly improve professional practice and, to a lesser extent, patient outcomes." Modest per meeting, and delivered at the scale of every meeting a specialty runs.

    Forsetlund L, O'Brien MA, Forsén L, Mwai L, Reinar LM, Okwen MP, Horsley T, Rose CJ. Continuing education meetings and workshops: effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD003030. DOI: 10.1002/14651858.CD003030.pub3.

  2. 02 / 11

    A systematic review examined 62 evaluations of the relationship between physicians' years of clinical experience and measures of care quality or knowledge. What did it find?

    Correct

    Not quite — the answer is C

    52% of the 62 evaluations found declining performance with more years since training across all outcomes studied, and another 21% found decline on at least some outcomes — only 4% found a positive association overall. Every one of the 12 studies specifically measuring physician knowledge found it decreased the longer a physician had been out of training. A related study cited in the review found roughly a 0.5% increase in patient mortality after acute MI for each additional year since the treating physician's medical school graduation.

    Choudhry NK, Fletcher RH, Soumerai SB. Systematic Review: The Relationship between Clinical Experience and Quality of Health Care. Ann Intern Med. 2005;142(4):260-273. doi:10.7326/0003-4819-142-4-200502150-00008. PMID: 15710959.

  3. 03 / 11

    A Cochrane review pooled 140 studies of audit-and-feedback interventions (where clinicians are shown data on their own performance) for changing professional practice. What was the median effect size found?

    Correct

    Not quite — the answer is B

    The weighted median absolute improvement in compliance with desired practice was only 4.3% (interquartile range 0.5% to 16%), and the effect varied widely depending on baseline performance and how the feedback was delivered. Audit and feedback is often treated as a reliable quality-improvement lever, but the median real-world effect is modest and inconsistent — comparable in scale to the didactic-vs-interactive findings in Q1.

    Ivers N, Jamtvedt G, Flottorp S, et al. Audit and Feedback: Effects on Professional Practice and Healthcare Outcomes. Cochrane Database of Systematic Reviews. 2012;6:CD000259. doi:10.1002/14651858.CD000259.pub3.

  4. 04 / 11

    By 2015, researchers had accumulated 39 systematic reviews of CME effectiveness spanning nearly 40 years (dating back to 1977). Synthesizing all of them, what did the authors conclude about the strength of evidence for CME improving physician performance versus improving patient health outcomes?

    Correct

    Not quite — the answer is D

    After synthesizing 39 systematic reviews spanning nearly four decades, the authors concluded that "CME does improve physician performance and, to a lesser and less consistent extent, patient health outcomes." The performance effect is one of the most consistent findings in the literature; the patient-outcome effect is real but harder to measure, because it sits several steps downstream of the room the education happened in. Which is the argument for building education that reaches into that room.

    Cervero RM, Gaines JK. The Impact of CME on Physician Performance and Patient Health Outcomes: An Updated Synthesis of Systematic Reviews. J Contin Educ Health Prof. 2015;35(2):131-138. doi:10.1002/chp.21290. PMID: 26115113.

  5. 05 / 11

    Researchers analyzed which specific design features predicted whether a clinical decision support system (e.g. a risk calculator or alert built into an EHR) would actually change clinical practice, across 70 trials and ~130,000 patients. Which single feature had the strongest statistical association with success?

    Correct

    Not quite — the answer is B

    Automatic delivery within existing workflow had an adjusted odds ratio of 112.1 (95% CI 12.9 to infinity, P<0.00001) for predicting success — a larger effect size than almost any drug in medicine. Three other features also predicted success: delivering the recommendation at the time and place of decision-making (OR 15.4), providing an actual recommendation rather than just an assessment (OR 7.1), and being computer-based rather than paper-based (OR 6.3). When all four features were present, 94% of systems (30 of 32) improved practice. In other words, the tool's clinical content mattered far less than whether it was simply shoved in front of the clinician at the right moment.

    Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ. 2005;330(7494):765. PMID: 15767266.

  6. 06 / 11

    A large multicentre trial introduced the Ottawa Ankle Rules — a simple bedside decision rule — across emergency departments and measured its effect on X-ray use for acute ankle injuries, compared with usual practice, in nearly 13,000 patients. What happened?

    Correct

    Not quite — the answer is C

    Across 12,777 patients, radiography use fell from 82.8% in usual-care hospitals to 60.9% where the rule was introduced (P<.001), with virtually no difference in fractures missed at ED discharge (0.5% vs. 0.4%). An earlier single-centre study found the same pattern in more detail: 28% relative reduction in ankle X-rays, 100% sensitivity for the fractures that mattered, and shorter ED visits (80 vs. 116 minutes) at lower cost — proof that a well-designed, well-implemented decision rule can cut unnecessary testing without missing significant injuries.

    Stiell IG, McKnight RD, Greenberg GH, et al. Implementation of the Ottawa Ankle Rules. JAMA. 1994;271(11):827-832. PMID: 8114236. Stiell IG, Wells GA, Laupacis A, et al. Multicentre trial to introduce the Ottawa ankle rules for use of radiography in acute ankle injuries. BMJ. 1995;311(7005):594-597. PMID: 7663253.

  7. 07 / 11

    A randomized controlled trial across 19 Canadian hospitals tested whether using a validated pneumonia severity risk score to guide admission decisions could safely shift more low-risk patients to outpatient treatment, compared with usual clinical judgment. What happened?

    Correct

    Not quite — the answer is D

    In this trial of 1,743 patients, outpatient treatment of patients identified as low-risk by the score rose from 31% to 49% (P=.01), average bed-days per patient fell from 6.1 to 4.4, and IV therapy duration fell similarly — while quality-of-life scores and clinical outcomes were statistically equivalent between groups. Used well, a risk score let clinicians safely send roughly one in five more pneumonia patients home who would otherwise have been admitted.

    Marrie TJ, Lau CY, Wheeler SL, et al. A Controlled Trial of a Critical Pathway for Treatment of Community-Acquired Pneumonia. JAMA. 2000;283(6):749-755. PMID: 10683053.

  8. 08 / 11

    A prospective study of over 42,000 children with head trauma tested a clinical prediction rule designed to identify kids at such low risk of significant brain injury that a CT scan could safely be skipped. How well did the rule perform at correctly identifying children who truly had no clinically important brain injury?

    Correct

    Not quite — the answer is A

    In children under 2, the rule's negative predictive value for clinically important brain injury was 100% (95% CI 99.7–100%); in children 2 and older, 99.95% (95% CI 99.81–99.99%). Applying the rule would have safely avoided CT imaging in roughly 20–24% of children who were actually scanned, without missing injuries that mattered. Out of 42,412 children, only 376 (0.9%) had a clinically important brain injury — and the rule caught essentially all of them while sparing thousands of children unnecessary radiation.

    Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. PMID: 19759692.

  9. 09 / 11

    The "Christopher Study" tested an algorithm combining a clinical probability score (Wells score), D-dimer blood testing, and CT scanning to diagnose or exclude pulmonary embolism (PE) in over 3,300 patients. For patients classified as low probability with a normal D-dimer — who were left untreated and had no further imaging — what happened over the next three months?

    Correct

    Not quite — the answer is B

    32% of the full cohort (1,057 of 3,306 patients) had a "PE unlikely" Wells score plus a normal D-dimer; of the 1,028 who went untreated on this basis, only 5 (0.5%, 95% CI 0.2–1.1%) had a confirmed venous thromboembolism in the following 3 months — a failure rate low enough to be considered clinically safe. The algorithm as a whole completed management using only clinical scoring, D-dimer, and CT (no further testing) in 97.9% of the entire cohort.

    van Belle A, Büller HR, Huisman MV, et al. (Christopher Study Investigators). Effectiveness of Managing Suspected Pulmonary Embolism Using an Algorithm Combining Clinical Probability, D-Dimer Testing, and Computed Tomography. JAMA. 2006;295(2):172-179. PMID: 16403929.

  10. 10 / 11

    The Glasgow-Blatchford Score (GBS) is used to identify patients with upper GI bleeding who are at low enough risk to be managed as outpatients rather than admitted. When implemented prospectively, what happened to hospital admission rates for patients scoring zero (lowest risk) on the scale?

    Correct

    Not quite — the answer is C

    In the prospective implementation cohort, 22% of patients were classified as low-risk (score of 0); of these, 68% were managed entirely as outpatients with no adverse events — no deaths, no rebleeding. Hospital admission for this population fell from 96% to 71% (P<0.00001) once the score was put into routine use. A four-question bedside score safely kept roughly a quarter of a high-stakes patient population out of the hospital altogether.

    Stanley AJ, Ashley D, Dalton HR, et al. Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Lancet. 2009;373(9657):42-47. PMID: 19091393.

  11. 11 / 11

    A meta-analysis of 7 randomized controlled trials (604 participants) compared case-based learning combined with problem-based learning against traditional lecture-based teaching in clinical medical education, measuring theoretical knowledge, practical skills, and clinical thinking. How large were the effect sizes found?

    Correct

    Not quite — the answer is D

    The pooled effect sizes were striking: theoretical knowledge SMD 2.16 (95% CI 1.22 to 3.11), practical skills SMD 1.59 (95% CI 1.04 to 2.15), and clinical thinking SMD 3.66 (95% CI 1.75 to 5.57) — all P<.0001 — plus a strong effect on learning satisfaction (0.86, 95% CI 0.81 to 0.91). These are unusually large effect sizes for an education intervention, several times bigger than most CME effects seen elsewhere on this list, though it should be read as case-based-plus-problem-based learning combined against lecture, not case-based learning in isolation, and is based on a relatively small pooled sample (604 participants across 7 trials).

    Lu B-R, Shi X-Y, An L, He K, Guo M, Sun Z-G. Effectiveness of case-based learning combined with problem-based learning versus lecture-based learning in clinical medical education: a systematic review and meta-analysis. Postgraduate Medical Journal. 2026;102(1209):615-625.

Out of 11. Every answer, and the paper proving it, is above.

Every figure here is drawn from a peer-reviewed source, cited in full. Nothing is paraphrased from memory, and nothing is ours.

Selected recent activity

The work, and who with.

Calculators, decision aids and accredited case simulations — built with medical societies and patient associations, live in eight countries. Nothing ships untested. We build the platform; the society keeps its own name, its data, its final clinical word.

ProjectAreaFacultyLink
Improving the diagnosis of Hypophosphatasia Rare Disease Richard Keen MBBS, Rachel Lombardo MD, Raja Padidela MD and Steven Petak MD View
Improving outcomes in the management of generalized Myasthenia Gravis (gMG) Neurology Renata Andrade MD View
Improving outcomes in the diagnosis and management of atypical hemolytic uremic syndrome (aHUS) Nephrology Bernat Herrera Gomez MD, Teresa Cavero Escribano MD, Gustavo Ferreira da Mata MD and Verónica López Jiménez MD View
Optimizing Outcomes in the Management of Multidrug-Resistant Gram-Negative Bacterial Infections Infectious Diseases Erin K. McCreary PharmD, Julian de la Torre-Cisneros MD and Matteo Bassetti MD View
Individualized care in solid organ transplant recipients in the post-transplant setting Nephrology Javeed Ansari, MD and Zahraa Hajjiri, MD View
Reflections and learnings from the early gene therapies for Hemophilia B Hematology Amit Nathwani MD, Frank Leebeek MD, Robert Klamroth MD and Wolfgang Miesbach MD View
Optimal treatment sequencing in advanced prostate cancerAlso in 中文FrançaisDeutsch日本語 Oncology Boris Hadaschik MD, Elena Castro MD, Laurence Klotz, MD, Stefano Fanti MD and Wolfgang Fendler MD View
Post-exposure prophylaxis (PEP) to varicella-zoster virus (VZV) Infectious Diseases Hayley A. Gans MD and Glenn R. Markenson MD View
Podcasts: Reflections and learnings from the early gene therapies for Hemophilia B Hematology Glenn Pierce PhD, Radek Kaczmarek PhD, Anne Galy PhD and Karina Meijer RN View
Unraveling the Cause of Relapsing Neurological Symptoms in a 51-Year-Old Female Neurology Tania A Reyna MD, MSCS, FAAN View
Case‑based Learning Module: Myelin Oligodendrocyte Antibody‑associated Disease. Neurology Sara Mariotto MD, PhD View
Pre-Transplant Risk Assessment (PTRA) in a 45-Year-Old African American Dialysis Patient. Solid Organ Transplant Richard Knight MD View
Early Detection of Kidney Transplant Rejection Using Non-Invasive Testing in the Post-Transplant Setting. Solid Organ Transplant Richard Knight MD View
Early Detection of Kidney Transplant Dysfunction in a 47-Year-Old Hispanic American Transplant Recipient. Solid Organ Transplant Richard Knight MD View
Improving the Assessment of Rejection and Injury in a Heart Transplant Patient. Solid Organ Transplant Gabriel Sayer MD and Eugene DePasquale MD View

Selected work. Full list available on request.

The data was never the problem — the system was. Guidelines and risk scores get proven, then sit untested at the bedside, doing nothing for the ill they were built for. We close that gap: your research, live in a clinician's hands — accredited, branded, running on almost anything.

hello@orakleinc.com

Who you work with

Publishing, engineering, and the clinic.

Small team, long memories, ten years on the same problem, and still starting from the evidence. Between us we have shipped medical education, priced risk, and sat on both sides of a pharmaceutical budget.

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