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Clinical Information Systems Getting the evidence

The challenge of implementing evidence-based medicine in tough global environments.

By Paul S. Auerbach, M.D. H

Paul S. Auerbach, M.D., FACEP, FAWM, is a professor of surgery at Stanford University School of Medicine. For more on Elsevier: www.rsleads. com/212ht-205

ealthcare needs evidence-based medicine (EBM) to move forward with new and emerg- ing opportunities, ranging from personalized medicine, chronic disease management and patient engagement to medical home, accountable care and population health management. However, as clinicians and researchers make progress on EBM, they should also consider the needs and capabilities of physicians who were educated without the latest and greatest technologies, or those who practice where resources are scarce.

Doctors find themselves in difficult environments more often these days. They can be on a mountainside or far out at sea practicing wilderness medicine, in a global humanitar- ian relief situation or even in the midst of a disaster. They can also be in a busy office practice, where time has been shortened for individual patient encounters and expectations for productivity run high. While medical professionals and health advocates are committed to offering the pinnacle of care to all patients, doing so isn’t always realistic or possible. Currently, EBM rests at a unique intersection of circum- stances. Where the circles of accepted data, clinical experi- ence and an improved situation in the eyes of the patient intersect, there emerges EBM. We can all agree that EBM is not simply having the latest facts taken out of context for the situations of the patient and practitioner. A truly dif- ficult global location or circumstance further complicates the situation.

With more and better evidence, physicians are under pressure to know everything all of the time. Technology is going to play a large role in helping physicians cope with that data deluge.

Imagine that you are practicing medicine on an isolated mountainside or far out at sea. Undoubtedly, there is evidence to be used, but unless it is at your fingertips precisely when you need it, the medicine practiced in these environments

18 December 2012

tends to be the best medicine one can muster. Constrained by limited resources, this brand of medicine can be grounded more in compassion and practical- ity than in clinical decision rules. Traditional data collection usually suffers, so observations may become more important and improvisation emerges as an indispensable clinical skill. This is not “silver platter medicine,” where the patients come to their providers with an adequate past medical history and reams of data, and there are enough helpers flocking to allow the luxury of downsizing the team.

Environments considered challenging to privileged urban practices include impoverished and underserved patient pop- ulations, working within an underdeveloped or dysfunctional nation and combat exposure. Challenges that are present in safe places are increasingly inadequate time and resources to develop relationships with patients and also keeping up with advances in medicine. In difficult environments, physicians discover the importance of three factors: clinical experience, intuition and common sense. Furthermore, what’s the value of experience? You know, the good old-fashioned kind, where the older you get, the wiser you’re supposed to become. When I presented this thought at a recent conference (“Transforming Healthcare Through Evidence-Based Medicine, a CMIO Leadership Forum”), I saw a lot of the CMIO heads in the audience nod in acknowledgement. With the rush to EBM and electronic medical records (EMRs), we are in some sense redefining our identities and our future as doctors. For example, following the 2010 earthquake in Haiti, I was working in Port-au-Prince and watched a strict, evidence-based approach argue against caring for many patients with extraordinarily serious injuries. For the most part, the standard rules of triage applied. Not surprisingly, there were exceptions. Convinced that a middle-age pa- tient with a severely crushed and mummified leg would die, well-meaning surgeons declined to operate on him for a few days, and tirelessly labored around the clock to save other persons who were predicted to have better outcomes. They looked at his leg more than his heart. But we insisted that the patient had a strong will to live, and he showed the

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