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May 07, 2006

Comments

Steve Beller, PhD

You bring up many excellent issues concerning EBM. Following are comments on some snips.

> EBM movement isn't about using artificial intelligence to get the perfect answer to every question in every situation. It's about getting all relevant facts in front of the clinician at the point of care and then trusting her to use her own judgment as to how the facts apply to the situation at hand.

True. It’s about helping clinicians make better diagnostic and treatment decisions using tools to increase their base of clinical knowledge about each patient, so their judgment is improved. Let me go one step further, the guidelines should enable clinicians to override the recommendations, present their reasons, and track whether such variance actually improves outcomes.

> Problems with implementing best practices have less to do with physician ignorance and more to do with systemic problems like fragmented record-keeping and lack of time to prep for encounters.

Actually, I would argue it’s often a combination of the two. The first is has to do with the knowledge void (http://wellness.wikispaces.com/The+Knowledge+Void) and the second refers to the need for a high-fidelity system (http://wellness.wikispaces.com/Tactic+-+Increase+Healthcare+Fidelity)

> What gets lost in the shuffle are often the long-term threads in the patient's care.

This points to the need for patient life-cycle health records and report that show meaningful trends.

> In the context of MS this meant not just knowing what the guidelines were for best practices, it meant total clarity about whether or not the advice was being followed by the patient and dogged insistence on sticking to the regimen … What was advised? How well has advice been followed in the past? What kinds of incentives and exhortations have been tried, which have worked and which didn't, and to the best of our knowledge, why or why not?.

An ideal EBM system would be able to track this information and advise the clinician accordingly. In addition, the guidelines should evolve to be more patient-specific, not simply based on a general diagnosis.

> The volume and quality of "evidence" in medicine is burgeoning, and controversies are as abundant as ever if not more so, but until we get the basics in place, it seems to me there's a lot of room for achievement before we get to the bleeding edge.

Yes. There’s much that must happen before EMB can improve effectiveness and control costs in a major way (http://wellness.wikispaces.com/Tactic+-+Improve+Care+Quality+with+Evidence-Based+Practice+Guidelines), and there are considerable challenges to its widespread implementation (http://wellness.wikispaces.com/Problems+with+Current+Practice+Guidelines+and+Quality+Improvement+(QI)+Programs+and+How+to+Solve+Them).

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