Evidence-based medicine moves forward with clinical decision support.
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.
Evidence-based medicine moves forward with clinical decision support.
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.