The practice of evidence-based medicine (EBM) is at the center of the tectonic shift to a value based delivery model currently sweeping through the healthcare industry. EBM, as defined by researchers at McMaster University in the early 1990's, represents a "systemic approach to analyze published research as the basis of clinical decision making." Driven by an intensified focus on improving value, healthcare organizations and medical specialty societies have adopted EBM as the principal strategy to enhance patient outcomes. Ultimately, it's about bringing established best practices to every clinical decision. These efforts have spawned development of a multitude of "clinical practice guidelines" (CPGs).
CPGs: the starting point
Commonly produced by specialty societies using standardized methods to grade the quality of the medical literature reviewed, these documents outline evidence-supported decision guidance for specific clinical situations. In the spine literature alone, more than 10 CPGs for low back pain have been published internationally in the last decade. As a member of the North American Spine Society Clinical Guidelines Committee for several years, I participated in the development of several guidelines and can attest to the rigor and effort involved in the process. For example, each member of our committee was required to complete several hours of formal training in evidence based medicine provided by McMaster University. The Institute of Medicine has published rules for developing trustworthy guidelines emphasizing the need to address potential conflicts of interest of developers and requirement for external review. The Agency for Heathcare Research and Quality (AHRQ) has established the National Guideline Clearinghouse (NCG) as a repository for CPGs with inclusion criteria and a requirement that the guideline be reviewed and revised at least every 5 years. Currently, more than 1900 guidelines are available in the NGC.
However well designed the guideline development process, the reality is that for many clinical decisions, high quality medical "evidence" is lacking. As a result, many guidelines are actually better termed "evidence-informed" with some recommendations based on "expert consensus" rather than irrefutable, hard, medical science. In the absence of evidence and lack of consensus, some guidelines simply don't make recommendations at these decision points but rather suggest "further studies are required to answer the question." I've previously addressed the variability in medical diagnosis and treatment. The surprising lack of definitive clinical studies to guide clinicians for even some very common medical problems is certainly a contributing factor.
Moving from the document to the exam room
Clearly the EBM movement has generated a small industry in guideline production. But how often are CPGs actually adopted by clinicians and result in changes in day to day practice? A study by the New England Healthcare Institute found that about two-thirds of physicians, irrespective of age or experience, described themselves as "light" guideline users. The reports found 4 major barriers to adoption of CPGs:
- Payment methods: emphasis on volume over outcomes
- Health IT: EMRs without point of care clinical decision support or access to guidelines
- Culture: no feedback to caregivers about guideline performance
- Guidelines: failure to reflect real world clinical complexity
Guidelines, however well conceived and evidence-based, won't impact practice or patient outcomes if they're inaccessible at the point of care. The challenge is to convert information in a document published in a medical journal into real time, clinically useful guidance for busy caregivers.
Clinical pathways represent a first line approach to provide the caregiver with the key elements of a guideline in an more easily digestible format. Designed to support implementation of CPGs, clinical pathways depict the decision points and plan of care in the form of a flow diagram of decision points rather than a multipage document. Pathways may address diagnosis, treatment, patient flow and range from outpatient, inpatient, and post acute phases of an episode of care.
Generally pathways provide broad guidance to the clinician based on the supporting CPG but may offer less specificity or fidelity for a particular patient encounter. For example, a sciatica pathway may suggest an MRI for a patient who doesn't respond to physical therapy but not detail the actual time line or define clinical variables used to define response. Locating pathways in an central and readily accessible (think mobile device or tablet) site optimizes their use at the point of care. For example, Penn Medicine hosts "Penn Pathways" in Dorsata, a referenceable library of more than 50 pathways across all service lines. Barnes-Jewish Hospital in St. Louis manages and distributes an entire library of antibiotic stewardship guidance within Dorsata, accessible on the caregiver's mobile device. A document on the desk in the office isn't helpful in the exam room. Moving pathways to a easily accessed online resource is much more likely to change caregiver behavior.
Workflows: Bringing pathways into the EMR and exam room
As any busy clinician can attest, the best solution to ensure adoption of the best evidence-informed principles of care would be to integrate the guidance into the actual face-to-face patient encounter itself, via the EMR. To build a so-called "workflow" requires collaboration of front line caregivers and software engineers using state of the art technology. A well-conceived workflow moves the content of the CPG down the continuum of care to the actual visit itself with greater fidelity than a pathway. At Dorsata, we've developed technology that converts a pathway into a full, comprehensive application that sits on top of the EMR driving more efficient documentation and order entry. Matching documentation to the actual flow of the patient encounter and providing guidance at decision points in a user friendly environment should improve patient care and clinician satisfaction. Removing the so-called "health IT barrier" to guideline adoption is a giant step forward in the evolution toward value-based patient care.
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