• December 2008 FEATURE ARTICLES •
Decision Support/EBM
Making the Most of EBM
Evidence-based medicine moves forward with clinical decision support.
By Randy Charles
Evidenced-based medicine (EBM), the
application of tested, measurable guidelines to the care of
individual patients in clinical settings, is poised to transform
the business of medicine. It reduces variability of care by
encouraging physicians and other clinical professionals to
follow best care practices as documented in evidence and
compiled in guidelines. This, in turn, improves the quality of
care and demonstrably improves outcomes.
But what can providers do — technologically
and managerially — to make EBM happen and improve patient care?
What’s required is an understanding of the intense need for
evidence-based care blended with clinical decision support
(CDS), as well as adherence to a discrete series of
implementation steps.
The Need for EBM and CDS
Just over half of Americans receive care that
complies with current recommendations, according to a 2003
article in the New England Journal of Medicine. The
article supported conclusions raised by the Institute of
Medicine (IOM), which discovered a gap "between the healthcare
we have and the healthcare we should have" in its 2001 report,
"Crossing the Quality Chasm."
Instead of delivering services supported by
solid evidence, the healthcare system functions with a limited
understanding of the advantages and benefits of various
interventions and invests resources in activities that fail to
improve care. This knowledge gap may only become deeper and more
dangerous with accelerated technology development and the
emergence of genomic medicine, predicts the IOM.
Efforts to achieve consensus on EBM have
emerged from groups as diverse as the IOM Evidence-Based
Medicine Roundtable and the Evidence-Based Practice Initiative
of the Agency for Healthcare Research and Quality, as well as
international programs such as the Centre for Evidence-Based
Medicine, the Evidence-based Medicine Working Group and the
American Health Information Community (AHIC).
Despite these efforts, healthcare providers
continue to face a dearth of standards and feeble national
consensus on EBM. Physicians are compelled to operate in an
increasingly time-pressured, stress-filled environment. They
must make medical decisions quickly with few or no opportunities
to evaluate the accuracy, credibility and timeliness of medical
literature.
Healthcare organizations also yearn for the
opportunity to measure their performance on standards, engage in
benchmarking and take steps to sustain good performance or
remediate problems. Writing in the Journal of the American
Medical Association, Steve Shortell asserts that authentic
quality care improvement is rooted in both EBM and
evidence-based management, defined as the identification of
"organizational strategies, structures and change management
practices that enable physicians and other healthcare
professionals to provide evidence-based care; i.e., the context
of providing care."
Providers can do much to enhance the uptake
and integration of evidence-based medicine. Actions include
support of standards to facilitate the transformation of
evidence into measures and interventions clinicians can easily
integrate into EHRs and other electronic tools. By delivering
the right information into the clinical workflow, physicians and
other healthcare professionals can make the right thing the easy
thing. Making the most of evidence-based medicine requires a
disciplined process involving the following steps:
Establish quality goals: Providers
need to focus on high-level quality goals such as improved
safety, compliance with clinical guidelines, enhanced patient
education and empowerment or improved outcomes for a particular
diagnosis, as well as lower-level measurable goals such as the
percentage of congestive heart failure (CHF) patients on beta
blockers. They then need to identify focus areas such as
diabetes or medication safety complemented by clinical goals and
objectives. A provider bent on fostering evidence-based
practice, for example, could focus on common outpatient
diagnoses with the goal of increasing compliance with
interventions in clinical evidence and the specific objective of
increasing the percentage of CHF patients taking beta blockers.
Establish and prioritize measures: A
provider aimed at improving disease management programs to
measurably enhance care processes and outcomes might focus on a
specific clinical goal such as prevention of diabetic
retinopathy supported by clinical actions such as increased
ophthalmology follow-up and annual funduscopic exams and
percentage increase in yearly ophthalmology exams as a measure
or success indicator. Providers can develop similar success
indicators or measures for clinical goals related to prevention
of diabetic neuropathy or unsafe drug use, lipid or blood
pressure management or glycemic control.
Make measures actionable by choosing
effective tools: Providers can take the lead in
supporting less cumbersome, easy-to-use tools and standards such
as order sets, decision support embedded within EHRs and nursing
care plans. With the goal of integrating evidence ever more
seamlessly into the workflow for easy access and
decision-making, providers can identify workflow opportunities
and specific CDS interventions. Such interventions can range
from order sets, and evidence-based interactive clinical
content, to drug decision support and interactive skills and
procedure protocols. Each type of CDS works best at different
points in the workflow. For example, order sets offer physicians
guideline-driven, reusable orders for medications, lab tests and
radiology studies.
Implement and use tools within the clinical
environment: Facilitating the movement toward EBM
through CDS tools also means evaluating the impact of various
interventions on workflow, finalizing parameters and targets and
developing a roll-out plan and schedule. Such a rollout should
include communication with users, a limited pilot phase,
routines for content, mechanics and support, leveraging use of
previously named champions and offering professional education
and training on CDS and its role in EBM.
Measure use of the tools: Evaluating
the use of CDS within EBM means looking at the impact of each
CDS intervention on workflow, quality and outcomes. Providers
should evaluate how interventions are used, as well as the
usability of the interventions. For example, say a provider
promotes the intervention of diabetic foot exams every six
months with the target objective of 90 percent of eligible
diabetics. The provider can then document performance against
the target, as well as related effects and plans to change or
enhance the value of the intervention. Above all, providers need
the ability to drill down for gaps in performance against
evidence-based guidelines, track and demonstrate improvement of
outcomes through analytics and perform remediation through
non-intrusive coaching, mentoring and quality programs focused
on changing processes, not people.
Take the lead: On a national level,
providers can support major initiatives such as those sponsored
by AHIC to establishing appropriate evidence-based guidelines,
while also insisting on reimbursement and payment for the
practice of evidence-based medicine. But not all change need
occur on a grand scale. Whether they work in an environment of
high or low automation, providers can lead the way by inviting
every member of the clinical team — nurses, therapists,
pharmacists and physicians — to join forces in the pursuit of
evidence-based practice and care.
Evidence-based medicine improves outcomes and
quality. While physicians and other providers have faced
challenges in implementing EBM, the choice and use of
appropriate practical CDS tools can help to make EBM a reality
in the world of healthcare and medicine.
Randy Charles is executive vice president,
Clinical Solutions Group, Elsevier Health Sciences. Contact him
at
R.Charles@Elsevier.com.
