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    The art of medicine: Applying evidence-based medicine drives improvements, creates partnerships

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    THE HEALTHCARE INDUSTRY has yet to use evidence-based medicine (EBM) to its fullest potential, in spite of studies that point to the need for it, such as the well-known 2003 RAND study, which states that Americans are receiving only about half of recommended medical care. Tremendous variation in medical practice and resulting clinical outcomes is indicative of the not-yet completed journey toward implementing evidence-based medicine.

    Experts concur that applying evidence to practice is an evolutionary process, lacking necessary tools and sufficient support from the healthcare community.

    David Eddy, MD, co-founder and medical director of Archimedes in Aspen, Colo., defines evidence-based medicine as "a set of principles and methods intended to ensure that, to the greatest extent possible, population-based policies and individual medical decisions are consistent with evidence of effectiveness and benefit." As he explains in the June 19, 2007, issue of Health Affairs, the term combines evidence applied to guidelines and evidence applied to medical education and to individual physicians' decision making.

    IMPLEMENTING EBM

    Across the spectrum, from payers and providers to disease management companies and government agencies, there is agreement about the key drivers of evidence-based medicine: transparency, need for a meaningful collection of data and systematic review of evidence, health information technology (HIT) at the point-of-care, and patient involvement.

    "The more you study, the more you learn, but you also find out how much you really don't know," says Paul Keckley, executive director, Deloitte Center for Health Solutions based in Washington, D.C. As medicine becomes more complicated and sophisticated, it is impossible for physicians to grasp all they need to know without mechanisms that can filter, sort and align evidence, pointing to the best solution for a specific patient situation, he says. The solution can be found in a combination of clinical knowledge management, transparency, experience and active patient involvement.











    Margaret E. O'Kane, president of the National Committee for Quality Assurance (NCQA), pins the lack of implementing EBM on the absence of a cohesive strategy for the development and deployment of medical knowledge.

    "There is an unmet need for evidence stewardship: a review of what we know, setting priorities for urgently needed science, and more effective deployment of medical knowledge through practice guidelines, decision support for clinicians and help for patients to make informed choices," O'Kane says. "There also has to be a link between appropriateness and the assessment of outcomes. Right now, an uneven evidence landscape exists. Some specialty societies have guidelines while others don't. We have redundant trials for many clinical areas and an absence or shortage of evidence in other areas."



    O'Kane points to the work of Peter Pronovost, a critical care specialist at Johns Hopkins Hospital. He developed a series of checklists and step-by-step guides for procedures in the intensive care unit, including infection controls, pain-medication management and mechanical-ventilation management.

    "Our research agenda is on treatments but not on how to deliver those treatments," O'Kane says. "The domains of medical science are biology, effective therapy and ensuring effective delivery of interventions, but the last one—the art of medicine—is ignored."

    As reported in the New England Journal of Medicine in December 2006, intensive care units in Michigan hospitals using a checklist decreased their infection rate by 66% within the first three months and saved an estimated $175 million dollars and more than 1,500 lives in the first 18 months.

    Pronovost acknowledged that the checklists not only helped with memory recall but also ensured that the minimum, expected steps for a complex process were explicit.

    J. Michael McGinnis, MD, a senior scholar at the Institute of Medicine (IOM), concurs with O'Kane that a decentralized approach to rendering judgment about appropriate evidence exists, prompting skepticism about any given recommendation.

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    Mari Edlin
    Mari Edlin is a frequent contributor to Managed Healthcare Executive. She is based in Sonoma, California.

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