Evidence-Based Medicine: The Present and Future of Hospital Care

Recently, health insurer WellPoint partnered with IBM's Watson technology in an effort to help physicians diagnose and design treatment plans based on large amounts of data and evidence. Watson is most commonly known for appearing on "Jeopardy!" and taking down two former champions with its data-crunching abilities. In many regards, it is considered to be the poster "bot" for decision-making based on evidence and technology, which is becoming the new standard in healthcare. The Institute of Medicine's Roundtable on Value & Science-Driven Health Care (pdf) predicts that "by the year 2020, 90 percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information and will reflect the best available evidence."

While many hospital and health systems have already implemented evidence-based medicine and processes of care, there are still several challenges chief medical officers will have to face, ranging from full updates of evidence, technology and support from hospital and other clinical leadership.

Critics of EBM are usually either patients or physicians — some patients trust their own physician more than guidelines, and some physicians might feel slighted that technology and outside sources are influencing their own clinical decisions. However, EBM is more than just technology and gathering evidence-based research, says James Leo, MD, medical director of best practice and clinical outcomes for MemorialCare Health System in Fountain Valley, Calif. "The purpose of evidence-based medicine is not to remove the 'art of medicine,' but rather to ensure that in the midst of practicing one's art, the known science regarding optimal management of an individual patient's condition is applied reliably and consistently," he says.

Previously, Dr. Leo was the associate chief medical officer at Long Beach (Calif.) Memorial Medical Center, one of six MemorialCare hospitals, and has helped lead a national effort to use predictive modeling, benchmarking and EBM to improve hospital care. Evidence-based practices shouldn't be looked at as "cookbook medicine," he says. It should be embraced because, in the end, it can help physicians deliver a higher level of care.

Players that need to be involved
Like any major decision at a hospital, the senior leadership must be on board. Dawn Vande Moortel, RN, MS, director of clinical training for Milliman Care Guidelines, says senior leadership of the organization has to give the appropriate support for EBM, and from there, case management departments, nursing leadership and physician leadership all need to work together to have a dialogue around the EBM and how to apply the guidelines to their daily work.

When it comes to the physician and nursing leadership, a hospital's CMO and chief medical information officer are integral in a hospital's transition to EBM. Dawn Walters, RN, assistant director of nursing at The University of Kansas Hospital in Kansas City, adds that the nursing informatics team also plays a key role through a strong collaboration with physicians. Nursing informatics is responsible for operationalizing the evidence into clinical workflows, resulting in action that allows the evidence to reach the patient.

The basics of EBM

EBM, simply put, is the combination of clinical expertise, patient preferences and the best research evidence to help the decision-making process for patient care. Evidence-based guidelines and sets can be found from numerous sources, and the overall goal is to aggregate the best data and use the conclusions to help come to a clinical decision. For example, a patient might be dealing with heart failure. Clinicians can pose a question and look for interventions to help the patient (does the patient need surgery, tests or prescription drugs?). Then after comparing it to other scenarios and research, clinicians outline their desired outcome and make a decision on how to treat the patient based on the process they just conducted. "When you are using the evidence-based source of information to manage care, you're going straight to the literature," Ms. Vande Moortel says. "It's not consensus opinion based on one or two practitioners. You're using the best possible approach to care management."

EBM also touches every specialty within a hospital setting, Dr. Leo says. Whether a patient has a risk for formation of blood clots that can break off and travel to the lung (involving numerous specialties) or whether a patient has a specialty-focused problem, such as coronary artery disease, physicians can find research on almost any condition and patient demographic. "Between global recommendations regarding hospital care and specialty-focused practices, there is literally no patient whose care cannot be positively impacted by evidence-based practice," Dr. Leo says.

For example, The University of Kansas Hospital recently went live with 240 evidence-based order sets deployed via computerized provider order entry, and the frequent updates of the evidence in their processes of care has helped them "to standardize patient care and ensure optimal patient outcomes," says Greg Ator, MD, CMIO for KU Hospital.

Best practices and challenges
Before a hospital decides to implement EBM, the leadership needs to assess the current clinical practice, how the clinical work has been accomplished thus far and what the organization is interested in accomplishing with EBM as the new foundation, Ms. Vande Moortel says.

After a hospital knows its general clinical direction, it can look to develop its evidence-based sets and processes of care. The development of tests and measures for evidence-based sets most commonly occurs at the health system level of larger organizations, and then the implementation of those tests and measures is delegated to the CMO at each hospital, Dr. Leo says. However, he adds that a successful transition to evidence-based practice must be multidisciplinary and inclusive.

For example, Dr. Leo notes that MemorialCare established an organization of physicians to implement EBM called the MemorialCare Physician Society. There are 13 "Best Practice Teams" chaired by a physician expert in the specific medicine covered by that team, and team membership consists of interested physicians, nurses, pharmacists and other healthcare providers for each specialty (e.g., cardiology, emergency medicine, women's health, neonatology, etc.). "It's our goal to ensure every team has at least one physician representative from each of our hospitals, preferably more than one," he says.

From there, the teams develop evidence-based protocols, which then undergo a comment period for recommended changes and input. "The sole requirement is that any recommended changes must be evidence-based, and the evidence needs to be submitted with the comment," Dr. Leo says.

After a hospital finds its direction and inclusively creates its order sets, how does a clinician actually access them? Electronic health records are becoming mainstream, and Dr. Leo says EHRs could easily make the practices accessible. For example, MemorialCare has built the evidence into its inpatient and ambulatory EHRs as well as the rules and alerts that help prompt the clinician to their use. Clinicians can simply click on embedded links to see the literature and rationales.

However, there are concerns of an overdependence on technology being fused with clinical decisions. Some have wondered what happens if the gathered research and technology medium create an error. Dr. Ator refutes that point, though, saying if hospitals and clinicians take all the right steps and do everything by the book, EBM is seamless. "Computers don't make mistakes," he says. "Humans who make computers and humans who input data into the computers make mistakes."

EBM has been a large part of the modernization of today's healthcare, and many see it becoming widespread in the future as more emphasis is put on taking the time to find the right diagnosis and enacting quality care to eliminate chronic illnesses. "If we're getting into a value-based system, the accountable care model, accountable care requires accountable providers, physicians, nurses, ancillary services to be looking to the evidence for the standard of care," Dr. Ator says.

Related Articles on Evidence-Based Medicine:

10 Proven Ways to Reduce Hospital Readmissions
6 Areas of Health IT and Accountable Care Integration
How to Use Evidence-Based Medicine, Clinical Decision Support to Succeed as an ACO

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