There are many reasons why people favor particular study designs in the context of producing systematic reviews. In a Cochrane context, this choice has historically been guided by the type of design that was most likely to produce robust research findings: the randomized controlled trial, recently extended with a theoretical option of high quality observational research without confounders (GRADE: Grading of Recommendations Assessment, Development and Evaluation). It was argued that decisions toward patients and clients should primarily be based on such evidence. In this paper we argue that this is a destructive choice for two main reasons: 1) it would prevent us from acting in a situation or event for which no robust evidence is available; and, 2) it would lead to an undesirable hierarchy of research questions, with more complex questions not being answered (or funded). We propose two models to respond to these issues: 1) a model integrating external (research driven) and internal evidence (client driven) in supporting evidence-based decision making; and, 2) a question-driven model for a mega-synthesis approach to support review authors in tackling a broad variety of questions. If we are serious about improving health care practice at the point of care, then we should investigate the conditions for realizing a coherent decision making process, based on the evidence that is available (not unavailable) to us.