Evidence-based medicine is a key component in reaching healthcare reform's goals of higher quality and lower costs. CMS' proposed rules for accountable care organizations, for example, include a requirement to set up a process for promoting evidence-based medicine. However, it has been widely reported that only approximately 15 percent of medicine is based on evidence. Jeffrey S. Rose, MD, vice president of clinical excellence and informatics at St. Louis-based Ascension Health, discusses four ways hospitals can encourage the use of evidence-based medicine to increase the quality of care, patient safety and savings.
Where's the evidence?
Evidence of effective medicine comes in two forms, Dr. Rose says: One is scientific evidence, either from double-blind randomized clinical trials or literature research reviews; the second is experiential evidence, practices that physicians have judged effective through their treatment of patients. "To practice current, good, informed care, you need to access both those sources of evidence," Dr. Rose says.
There are several reasons for the low rate of adherence to evidence-based medicine, one of which is unawareness of the evidence for or against a certain practice. "One of the biggest myths is that doctors can keep up [with the evidence], even if they're in a narrow field of practice," Dr. Rose says. For example, Dr. Rose says it has been routine to put patients with hypertension on a low-salt diet, but recently people have revisited the literature and found there is little evidence for the effectiveness of the practice. He attributes this inability to stay current with the literature to the "explosion of information" and the difficulty of gauging the quality of the information being published.
Other examples of common practices that are not based on evidence include routine ankle X-rays for ankle trauma, chest X-rays prior to anesthesia, antibiotics for upper respiratory viral infections, MRI studies for low back pain and a host of other questionable procedures both in the acute care and ambulatory settings, according to Dr. Rose.
On the other hand, many providers may be aware of evolving knowledge but maintain their practices out of habit or because the evidence has not been presented in an effective way. "[When a practice has attained] mythical status, everybody believes what should be done. If you make evidence to the contrary available, at least there is a consideration at the time of treatment rather than 'This is how I always did it,'" Dr. Rose says. Reimbursement also plays a role in the use of evidence-based medicine. "I don't think greed is a factor," Dr. Rose says. "But certainly if you're getting paid for a study that's of no value, you're less likely stop doing it." Conversely, providing evidence and guidance that improve care practices, efficiency or reimbursement is more likely to succeed.
Now, the government is beginning to incentivize evidence-based medicine through healthcare reform measures, and providers may have to change how they practice medicine. "We really are going to have to shift in this new world to be more fluid with our habits and more reliant on what's changing and current and of demonstrable value," Dr. Rose says. Despite incentives, Dr. Rose says there is "resistance to change." Hospital leaders can break down this resistance by presenting solid, relevant evidence in a compassionate and accessible way to change the hospital culture. "Meeting resistance head on with intelligence and compassion and understanding and measuring outcomes is the way you gradually create culture change," Dr. Rose says.
Strategies
1. Present solid evidence. Hospital leaders need to present believable evidence that is relevant to the clinician's practice, Dr. Rose says. "When they [see] one or two pieces of information that are relevant and make a difference, they start to trust the system more." The evidence should be provided by a respected colleague from the group being addressed and tailored to the particular challenges facing that audience. "Direct, accurate peer group-related practice and outcome data speak loudly," he says.
2. Adopt a compassionate approach. Providing scientific evidence alone is not enough to change physicians' behavior; hospital leaders need to adopt a compassionate approach that respects physicians' skills and beliefs. "Unless [physicians] are compassionately presented with evidence contrary to their customs, they are very resistant to change," Dr. Rose says. Instead of singling out physicians for practicing "bad" medicine, leaders should have a conversation with physicians to understand their perspective and reasoning for their current practices, benchmarked against relative peers. In this approach, "People feel part of the system rather than being evaluated by 'Big Brother' for being a bad apple," Dr. Rose says.
Encouraging physicians to practice evidence-based medicine should also focus on patient safety, according to Dr. Rose. "In general clinicians don't respond when the approach is framed as 'a cost issue.' They respond much better to data addressing safety or quality issues, and safer, higher quality practices have been repeatedly shown to improve costs, especially in the evolving reimbursement environment."
3. Include links to information in EHR systems. The hospital's electronic health records should include links to the most current evidence or practice standards so physicians can easily access evidence-based medicine. "The way to make practice better is to present evidence at the point of care while patients are being treated," Dr. Rose says. "This is the best way to provide ongoing, current continuing medical education for your caregivers."
4. Use clinical decision support. Automated clinical decision support is another tool that can help physicians practice evidence-based medicine. This support would produce relevant alerts or reminders when physicians enter choices about a patient's treatment in the EHR. Dr. Rose says companies like Zynx Health compile and "grade" evidence so that the clinical decision support provided is based on the best evidence available. "If you get clinicians comfortable with alerts or reminders coming from a base of evidence that they trust, they change behavior," he says. "The major danger here is to barrage clinicians with alerts or reminders of little relevance in which case they may all be ignored because of 'alert fatigue.'"
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Where's the evidence?
Evidence of effective medicine comes in two forms, Dr. Rose says: One is scientific evidence, either from double-blind randomized clinical trials or literature research reviews; the second is experiential evidence, practices that physicians have judged effective through their treatment of patients. "To practice current, good, informed care, you need to access both those sources of evidence," Dr. Rose says.
There are several reasons for the low rate of adherence to evidence-based medicine, one of which is unawareness of the evidence for or against a certain practice. "One of the biggest myths is that doctors can keep up [with the evidence], even if they're in a narrow field of practice," Dr. Rose says. For example, Dr. Rose says it has been routine to put patients with hypertension on a low-salt diet, but recently people have revisited the literature and found there is little evidence for the effectiveness of the practice. He attributes this inability to stay current with the literature to the "explosion of information" and the difficulty of gauging the quality of the information being published.
Other examples of common practices that are not based on evidence include routine ankle X-rays for ankle trauma, chest X-rays prior to anesthesia, antibiotics for upper respiratory viral infections, MRI studies for low back pain and a host of other questionable procedures both in the acute care and ambulatory settings, according to Dr. Rose.
On the other hand, many providers may be aware of evolving knowledge but maintain their practices out of habit or because the evidence has not been presented in an effective way. "[When a practice has attained] mythical status, everybody believes what should be done. If you make evidence to the contrary available, at least there is a consideration at the time of treatment rather than 'This is how I always did it,'" Dr. Rose says. Reimbursement also plays a role in the use of evidence-based medicine. "I don't think greed is a factor," Dr. Rose says. "But certainly if you're getting paid for a study that's of no value, you're less likely stop doing it." Conversely, providing evidence and guidance that improve care practices, efficiency or reimbursement is more likely to succeed.
Now, the government is beginning to incentivize evidence-based medicine through healthcare reform measures, and providers may have to change how they practice medicine. "We really are going to have to shift in this new world to be more fluid with our habits and more reliant on what's changing and current and of demonstrable value," Dr. Rose says. Despite incentives, Dr. Rose says there is "resistance to change." Hospital leaders can break down this resistance by presenting solid, relevant evidence in a compassionate and accessible way to change the hospital culture. "Meeting resistance head on with intelligence and compassion and understanding and measuring outcomes is the way you gradually create culture change," Dr. Rose says.
Strategies
1. Present solid evidence. Hospital leaders need to present believable evidence that is relevant to the clinician's practice, Dr. Rose says. "When they [see] one or two pieces of information that are relevant and make a difference, they start to trust the system more." The evidence should be provided by a respected colleague from the group being addressed and tailored to the particular challenges facing that audience. "Direct, accurate peer group-related practice and outcome data speak loudly," he says.
2. Adopt a compassionate approach. Providing scientific evidence alone is not enough to change physicians' behavior; hospital leaders need to adopt a compassionate approach that respects physicians' skills and beliefs. "Unless [physicians] are compassionately presented with evidence contrary to their customs, they are very resistant to change," Dr. Rose says. Instead of singling out physicians for practicing "bad" medicine, leaders should have a conversation with physicians to understand their perspective and reasoning for their current practices, benchmarked against relative peers. In this approach, "People feel part of the system rather than being evaluated by 'Big Brother' for being a bad apple," Dr. Rose says.
Encouraging physicians to practice evidence-based medicine should also focus on patient safety, according to Dr. Rose. "In general clinicians don't respond when the approach is framed as 'a cost issue.' They respond much better to data addressing safety or quality issues, and safer, higher quality practices have been repeatedly shown to improve costs, especially in the evolving reimbursement environment."
3. Include links to information in EHR systems. The hospital's electronic health records should include links to the most current evidence or practice standards so physicians can easily access evidence-based medicine. "The way to make practice better is to present evidence at the point of care while patients are being treated," Dr. Rose says. "This is the best way to provide ongoing, current continuing medical education for your caregivers."
4. Use clinical decision support. Automated clinical decision support is another tool that can help physicians practice evidence-based medicine. This support would produce relevant alerts or reminders when physicians enter choices about a patient's treatment in the EHR. Dr. Rose says companies like Zynx Health compile and "grade" evidence so that the clinical decision support provided is based on the best evidence available. "If you get clinicians comfortable with alerts or reminders coming from a base of evidence that they trust, they change behavior," he says. "The major danger here is to barrage clinicians with alerts or reminders of little relevance in which case they may all be ignored because of 'alert fatigue.'"
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