Reading this post on Technology Support for Evidence-based Medicine, I began to wonder if EBM isn't sometimes overblown - mostly by folks trying to point out its limitations. The way I see it, the 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.
If we look at EBM as an attempt to raise the quality of patient care, the first thing we need to recall is that the bar is pretty low. A recent report from an authoritative source has shown that regardless of disease, demographics, or economic stratum, the probability is roughly equivalent to a coin toss as to whether the patient is going to get the right care in any given situation. If we could up that to two out of every three times on average, it would be a huge win, given the number of clinical encounters that occur every minute of every day.
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. A 15- to 30-second reading of the chart outside the exam room door is par for the course. As a result there is a strong tendency to focus on presenting signs and symptoms and patient report of the reason for the encounter. What gets lost in the shuffle are often the long-term threads in the patient's care.
A 450-pound diabetic in the clinic for urgent care for a gangrenous right foot will get the best advice possible as to handling his diabetes, but what about the patient who is only mildly overweight and is in for a sinus infection? Will she be asked about her adherence to her diabetes medication regimen, and reminded to keep a close eye on her extremities and get a vision exam sometime in the next month? If the family practitioner has 600 active patients and is working a 55-hour week plus on-call hours, the answer may be no, even though given the right knowledge at the right time, best practices in this case are a no-brainer.
An EHR accessible at patient bedside with the same or less effort as looking at the hard-copy chart would be a huge step in the direction of EBM. If the EHR could also point out the things that obviously need to be asked and said given comprehensive knowledge of this patient's condition, what a breath of fresh air that would be.
Once we have a workable real-time-accessible EHR at all at bedside or in the exam room, we can look at the order-of-magnitude increases in quality that could come from linking EHRs together. If a patient should be running out of her meds every 30 days but is refilling her scripts ever 40 days, there is a problem with therapy compliance, a problem that could be easily identified if the clinic and pharmacy records are linked.
Bormel refers to a 2004 New Yorker article from a while back that talks about the difference between good treatment and great treatment in multiple sclerosis. it comes down to focus, aggressiveness, and inventiveness. 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. This is a low-tech solution that requires a commitment to excellence on the part of the clinician and some very achievable information technology support. 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?
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.
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).
Posted by: Steve Beller, PhD | May 11, 2006 at 02:04 PM