Parsing the Evidence

Last year, Bill Fera, M.D. transitioned from being a physician informaticist at the University of Pittsburgh Medical Center (UPMC) health system to becoming executive director in the Health Care Advisory Services practice at the New York-based Ernst & Young consulting firm. Fera, who remains Pittsburgh-based, has years of experience working with the concepts and practices around evidence-based patient care. That topic is the subject of the cover story in the January issue of Healthcare Informatics . Fera spoke recently with HCI Editor-in-Chief Mark Hagland regarding where the evidence-based care phenomenon is at the moment and where it’s going.

Healthcare Informatics: What’s your perception of the needs around evidence-based order sets and where things are going?

Bill Fera, M.D.: I think people start with the notion that they can do this all themselves. There’s some ego involved, and everybody believes that they have a better mousetrap. But the evidence could be changing on a monthly basis, and when it comes to maintaining and updating those order sets, it doesn’t really make sense to do it all in-house. I’m also intrigued with what Isabel [the Ann Arbor, Mich.-based Isabel Healthcare, which offers evidence-based clinical decision support for medical diagnosis] does, and I think they’re exactly on the right track. And the ability to pull out symptoms and history from what’s going into the medical record, and receive diagnostic suggestions, is very neat. I think the government is trying to push everyone in that direction—if you look at comparative effectiveness, at meaningful use, at ICD-10, the government wants us to move forward in various ways in this area. In Canada, they have something called the Cochrane Database that supplements their use of ICD-10.

You can make all these kinds of information available to everyone, if you have the right data infrastructure. And so if you look at the long-term view of meaningful use, ICD-10, and comparative effectiveness, I think you see a view of data-driven medicine. And I think that what you also see with ICD-10 and comparative effectiveness and this availability of data, is this ability of payers and providers to partner in areas of mutual interest.

HCI: There has historically been a lack of trust between the two groups.

Fera: Yes, and part of that is because of the past lack of transparency and availability of data. Payers have their data, and providers have theirs. But through ICD-10 and comparative effectiveness, everybody now begins to have access to the same data, and can make that new paradigm real. And then with the next step, from the Isabel standpoint, you see some real opportunities.

HCI: What kinds of challenges and opportunities do you see ahead?

Fera: The next step that people are looking for, and what electronic medical records should enable, is this virtual collaboration—the ability to share information in real-time, and to have that information be available to whoever is using the electronic record system—establishing a common portal, so that everyone can look at the same types of information and evidence.

HCI: So, for example, that the referring physician and specialist can look at the same information?

Fera: Yes, exactly. Historically, if a primary care physician doesn’t send a referral letter to a specialist, they don’t know what they’re looking at; they’re seeing patients blind, if you will. And certainly that’s true in the ED. But the more that you can look at the patient’s history, and at the evidence you can apply to the situation, in a collaborative framework, the more you can improve care. I think that’s the next step forward for the electronic medical record from the operational standpoint; we still haven’t realized the ability to do full clinical data analysis, but the ability to collaborate in real time on care is the next area of development.

HCI: How quickly are physicians moving to understand the potential benefit of these types of tools?

Fera: I think the change is taking place; some of it is generational. There are physicians now coming into the marketplace who are used to working on a computer all the time, who are used to technology helping them do their jobs. And, to one of the arguments put forward against ‘cookbook medicine’—that ‘My patients are all different,’ etc.—I say, of course your patients are all different; and that relates to the art of medicine. But if you can turn to supports for the more mundane parts of your job, that can help you really do your job better with your patients in the more creative aspect. And perhaps the combination of some sort of tort reform in combination with the use of these tools is a potential leveraging point that should be explored. And it gets to decreasing the variable definition of best practice. If you’re using the accepted evidence-based tools, automatically, you’re using best practice; and most often, in medical malpractice cases, it’s deviation from best practices that gets people.

HCI: What’s the role of the CIO, CMIO, the CEO of the medical group, in all this?

Fera: Where your organization is successful is where your CIO and your CMIO, are functioning in a more strategic role, and where technology implementation is about executing strategy. In some cases, CIOs might still see themselves as technology people, but really, that [level of functioning] should be one level down, and the folks at the levels below that person should be executing strategy. I think if you follow that paradigm where your CIO and CMIO are strategists, that will help tremendously. If you say that we’re going to build an electronic record because it improves patient care, and we’re going to pursue HIE [health information exchange] because it leads to the best care, that’s where you gain consensus. That’s where we were able to achieve adoption at UPMC, was at that strategic level, and that naturally led to adoption.

As long as your motive is pure and admirable, which hopefully most strategies are, people can understand and follow through. Because it’s always the change that is the hardest part. And you hear that in electronic medical records all the time. People using them say, I’d never go back to paper. Do you ever hear people say they liked the changeover? No. But if you can communicate those motivations and strategies, you can motivate them through the change and help them understand why they did what they did.

HCI: What would your advice be for non-clinician CIOs and CTOs, as they seek to understand the concepts around evidence-based care and help clinicians and clinical informaticists implement evidence-based care practices?

Fera: It’s pretty easy, actually. Get out of the office: go watch people work, go talk to people where they work. I know Jacque Dailey [Children’s Hospital of Pittsburgh’s vice president and CIO, Jacqueline Dailey] is a nurse, so maybe it’s not quite the same, but she was so successful at Children’s Hospital because she would always round, she would check to make sure the carts were where they should be, and she was very visible. And at that point, it didn’t matter that she was a nurse, because the front-line clinicians knew that she cared. And it will help people understand the impact.

HCI: What’s the horizon over the next few years in terms of the ramp-up to adoption of evidence-based care practices?

Fera: My hope and expectation is that the evidence is going to get stronger and stronger. And with that, it will become harder and harder for people to ignore it. And the more data we’re getting now with the push to meaningful use and the ramp-up to ICD-10, the stronger will be the evidence we’ll be obtaining to support care practices.