The following article is written by Stephen Claypool, MD, vice president of clinical development and informatics for Wolters Kluwer Health.
A new initiative on the national level focuses on an identified quality gap that exists in healthcare today. This gap has been defined by the Agency for Healthcare Research and Quality as the difference between what is expected to work well for patients based on known evidence and what actually happens in day-to-day clinical practice. Christine Chang, MD, MPH, medical officer for the AHRQ, notes that recently acquired evidence supports the assertion that "for every patient who receives optimal care, on average another patient does not."
As national initiatives continue to raise the bar on expectations for quality outcomes going forward, the need to stay informed of current professional knowledge and changes to industry best practices will be crucial to effective and efficient delivery of patient care. Meeting this need is the premise behind the movement toward evidence-based medicine (EBM).
This new series of reports initiated by the AHRQ — Closing the Quality Gap: Revisiting the State of the Science — aims to identify strategies that will help make the use of industry best practices more consistent across the industry.
This initiative, like many across the nation, is part of a purposeful effort to provide critical resources to support the use of evidence-based techniques — the impact of which has been proven to result in dramatic improvements to patient care and safety. And while the overriding benefits of incorporating EBM cannot be denied, adoption rates remain low.
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Multiple reasons exist for this lack of momentum. Most notably, with 2 million scientific articles published annually, the sheer volume of research is overwhelming. Indeed, the average physician would need to read 19 articles every day just to keep up.
The current AHRQ effort has been formulated around a concept introduced by Victor Fuchs (National Bureau of Economic Research, Stanford University) that suggests real reform ". . . requires changes in the organization and delivery of care that provide physicians with the information, infrastructure, and incentives they need to improve quality and control costs." In their own efforts to leverage cutting edge research and best practices, healthcare organizations can build off of these same principles to introduce EBM into workflow and close gaps in quality.
Information
The quality movement in healthcare is perhaps best defined by the Institute of Medicine as "the degree to which healthcare services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."
By extension, practicing physicians need assistance to stay current amidst a steady stream of new research, such as the issuance of timely practice guidelines or evidence summaries from professional organizations and other trusted resources. Since it is unrealistic to suggest that healthcare organizations or physicians can accomplish this feat on their own, the obvious next step is to find trusted external resources that can fill in the gaps.
That's where clinical decision support (CDS) tools can impact the success of an organization's efforts to introduce EBM into the workflow. Key to the introduction of CDS tools is their alignment with a trusted resource that will be credible to the physicians using them.
It is also important to note that guidelines alone are not enough to facilitate change. The process for incorporating new evidence has to have as little effect on physician workflow as possible, allowing ease of use.
Infrastructure
The best way to ensure successful deployment of EBM is to leverage a technological infrastructure that streamlines integration of the latest evidence into clinical workflows. Among the most powerful methods are automated interventions for CDS that identify when new clinical procedures could be applied to care decisions.
These interventions can take a variety of approaches, each designed to address a specific format for incorporating new evidence into practice:
- Documentation forms and templates: Tools such as smart forms or clinical documentation systems capture structured data for use throughout the patient encounter and create a longitudinal care record, all incorporating best practices that alert physicians to required care.
- Relevant data presentations: These applications provide alerts to physicians that address key statuses that can impact care decisions. They can also include retrospective or aggregate reporting, such as practice audits and feedback, report cards or lists of patients due or overdue for preventive care interventions.
- Order creation facilitators: Supported by multiple trials indicating their utilization increases adherence to guidelines, these intervention tools take multiple forms. For example, single-order completers prompt for appropriate orders and documentation, while order sets contain orders that are fully specified and are based on active guidelines. Creation facilitators also include tools for complex orders, such as guided dose algorithms, and computable guidelines.
- Time-based checking and protocol/pathway support: These interventions create an ideal pathway through the healthcare system for a patient with a specific medical condition or problem. They provide stepwise processing of multi-step protocols or guidelines and support for managing clinical problems over long periods.
- Reference information and guidance: Since they provide a general link from an EMR to a reference program or a direct link to specifically selected, pertinent reference material, physicians often find this form of CDS the most useable.
- Reactive alerts and reminders: These can include alerts to prevent potential errors or hazards, such as drug-allergy or drug-interaction alerts, and alerts to foster best care, such as disease or wellness management alerts.
Incentives
Even with a solid technological infrastructure that provides ease of use for accessing the latest evidence, industry studies reveal that guidelines by themselves will only go so far in impacting the successful adoption of EBM. Guidelines may predispose physicians to consider changing their behavior, but without other incentives or the removal of disincentives, guidelines may be unlikely to trigger rapid change in actual practice.
Many efforts are underway on the national level to encourage physician adoption of EBM practices to improve quality and outcomes. Specifically, the shared savings program for accountable care organizations provides incentives for the use of coordinated care to meet or exceed quality performance standards.
The Comprehensive Primary Care Initiative is also an incentive program set up to increase Medicare payments to primary care providers who adopt a coordinated care model. The parameters specifically focus on teamwork among primary care doctors, specialists and other providers with particular focus on prevention and better management of chronic disease.
Conclusion
Despite slow adoption, the impact EBM has had on quality and safety of care across the healthcare system has been significant. As such, it is imperative that solutions be identified that accelerate the pace at which physicians can integrate new medical evidence into practice.
National initiatives like that of the AHRQ are providing a framework for healthcare organizations to begin drawing on best practices to close gaps in quality. By instituting a process of information, infrastructure and incentives, healthcare entities can begin the process of successfully raising the bar on the practice of EBM.
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