n 2001, the senior administration at NorthBay Healthcare Group decided to convert from a paper-based healthcare system to one that, as much as possible, was completely electronic. One of the foundation principles in the strategic plan was to make the choice between “best of breed” and an “integrated health record.” We chose the latter and invited nine to 10 vendors to submit proposals. The steering committee reviewed each and weeded out the interfaced electronic health record systems (EHR) from the truly integrated EHRs, and, after much due diligence, chose one for installation.

The fully integrated EHR improved our ability to track physican activity for recredentialing purposes, documentation and completion of medical records. It also improved workflow and turnaround time for results. And, everyone appreciated the elimination of the notorious cursive handwriting and subsequent need for interpretation.

We now have 30 applications implemented, including five patient management systems and 25 patient care systems, and are continuing to implement more systems, such as PACS and CPOE.

CPOE and EBM

The NorthBay Healthcare System includes two hospitals — the 140-bed NorthBay Medical Center (NBMC) and the 50-bed VacaValley Hospital, a fully-accredited regional cancer treatment center (medical and radiation oncology) — occupational health services, the NorthBay Center for Pain Management, three primary care centers, and several specialty practices and other ancillary services for the community.

As the implementations proceed, we are preparing for one of the final clinical applications — computerized physician order entry (CPOE). In our approach to this phase, the physicians evaluated our current state and made significant decisions regarding our future state and the tools we would use to develop our order sets.

The decision making related to the inclusion of evidence- based medicine (EBM) and standardization/evidence-based management (EBMgt), organizational governance, CPOE vision, future state model, CPOE deployment priority, CPOE deployment approach, communication and change management.

Decisions in the respective areas would become foundational positions for moving ahead in the project. Achieving optimal patient outcomes and optimal resource utilization through the use of EBM and EBMgt was set as a priority.

David L. Sackett, M.D., and his colleagues from McMaster University, defined EBM as: “The conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. By best available external evidence we mean clinically relevant research, often from basic sciences of medicine, but especially from patient-centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative and preventive regimens.”

The application of outdated clinical evidence is a discredit to the patient and the unfiltered use of even the best clinical evidence in the absence of clinical experience and expertise generates potential risk to the individual patient.

Content and Context

EBM has at its core a voluminous body of refined clinical content that has been critically evaluated from three aspects that combine the art and science of medicine.

In the first instance, the science of EBM comes from the rigorous, objective and academic evaluation of the medical literature synthesizing relevant original clinical research and meta-analysis study results into refined, usable clinical evidence. The criteria for evaluation of the various sources have been formalized and outlined in a series of articles published in several sources and are also available online.

Secondly, we must be addressing a properly formatted clinical question for which we need an answer such that the appropriate evidence has clinical relevance. In this context the physician has identified the clinical context in which the patient presents with a defined problem requiring an intervention with an expected outcome.

The art of medicine comes into the third component of the clinical application. The physician, through critical thinking, must decide if the EBM application is appropriate for his or her patient in the present clinical setting.

We need to look at the available evidence in the context of the patient and make sure that we are applying a recommendation that will result in making a positive difference in the outcome for the patient without increasing risk. This is the integration of EBM and EBMgt, or the integration of content and context, to maximize the use of resources in decision making and care provision for the patient.

Therefore, as we select the EBM source for CPOE there are specific issues that should be addressed and criteria met to ensure that we are presenting appropriate, usable and current recommendations.

Expectations, Accessibility and Credibility

To meet this end, we need to define our expectations and the accessibility and credibility of the EBM.

Content Expectations: This could be best summarized with the following principles. The pertinent summary information of the EBM/EBMgt should be synthesized and presented on a single viewable page and in a logical fashion enabling the physician to quickly assess the source for the recommendations. There should be references readily available to access detailed explanations of the recommendations from the supporting studies with appropriate links to the original source research articles. The content should incorporate best practice recommendations and up-to-date clinical content that is appropriate to the clinical scenario and patient management under consideration.

Trustworthy Information: The information needs to meet the criteria for strength of evidence by international standards with appropriate grading of the supporting research from which the guideline or recommendation was generated.

This information also needs to be current and updated on a systematic and regular basis. Real time access to this information base that is imbedded in or directly linked to the order or order sets helps to overcome the barriers to the use of EBM and EBMgt.

Issues such as time barriers, perceived threats to autonomy, the default thinking of decision or choice based on local knowledge or individual experience, and difficulty in accessing the relevant information are addressed in the design and build process.

The Approach to Implementation

We have evaluated ZynxHealth and find that their format and process clearly meet these criteria and become a reliable and accurate source for the EBM clinical content and EBMgt design for our order sets at NBMC. We will default to their content and recommendations as the starting point for the building of our order sets. We will then refine them as applicable to our local “community and culture” and, where appropriate, incorporate the content of the order sets currently approved and in use at NBMC.

We will be relying on the focus design teams from our medical staff and clinicians to direct the process and then make these order sets available in Zynx ViewSpace for review and feedback on clinical content and design by the members of the related departments and medical staff. During the design phase, the focus team will be seeking the input from colleagues in their related departments. In addition, the content of ZynxHealth links the order set content to core measures, patient safety goals, The Joint Commission and other regulatory requirements that have defined improved patient outcomes or current best practice standards.

The EHR Advantage

The integrated EHR throughout the system has greatly enhanced the clinic provider’s ability to monitor their patient’s care while in the hospital. The hospitalist, consulting specialist and ED physician are now able to access the patient’s office records while attending the patient in the inpatient setting. This enables them to see results of outpatient investigation and clinical management and reduce the duplication of expensive testing. Medication reconciliation and discharge prescribing become more efficient and safer with greater knowledge of current meds, past failed meds or potential drug-drug interactions from unlisted home meds missed on intake documentation on admission.

This ability to see the patient’s record for office, ancillary services and inpatient care can significantly improve communication and access by all care providers to a more complete medical record. All physicians caring for the patient have equal access to the EBM/EBMgt sources to facilitate patient-centered decison making for a common ground.

The current ability for the community physician to remotely access the patient’s EHR and follow their patient with access to the clinical documentation, the supporting medical literature and recommendations for best practice standards of care has significantly improved their access to point-of-care information for decision making and planning, post-discharge follow-up and care.

Moving Forward

Following the CPOE implementation, we will expand the use of current applications to include documentation by ancillary services, thereby achieving optimal use of the integrated system. Incorporating best practice standards that are supported by available EBM resources will enable more efficient communication and preventive care in the clinical setting, as well as improved outcomes for disease management.

March 2008