EVIDENCE-BASED MEDICAL PRACTICE IN THE 21st CENTURY

Introduction

• This EPS Focus Report describes how knowledge, data and information technology are being fused together to make the process of practicing medicine simpler, more transparent and above all, more effective.
  The scope will include both:
  • the process of gathering information and identifying best practice (Evidence Based Medicine, EBM, in its strictest sense);

  • the methods used to present this knowledge to support decisions made by the clinician and patient (Clinical Decision Support - CDS).

Drivers for change

• The increasing complexity of healthcare and cost of the underlying technologies needed to deliver these benefits, coupled to a prejudice that ?latest means best?, has become the major driving force.

• Medical errors are now one of the leading causes of death. Based on the findings cited by a study from the US Institute of Medicine (IOM), medical errors kill some 44,000 people in US hospitals each year.

• The IOM emphasized that most medical errors are systems-related and not necessarily attributable to individual negligence or misconduct. The key to reducing medical errors then is to focus on improving the systems of delivering information - healthcare professionals are simply human and, like everyone else, they make mistakes - and repeated research studies have shown that system improvements can reduce the error rates and improve the quality of healthcare.

• Today, the sheer volume and complexity of new medical information greatly exceeds the capability of the human brain to assimilate it - either by writing about or memorizing it. This means that the gap between what doctors might do (based on an evidence-based consensus informed by best clinical practice guidelines, costs and patient outcomes) and what they actually do is wide, variable and growing.

• Even if information is available at the point-of-care, its usefulness and relevance is conditional on an increasingly complex data stream from the individual patient, e.g. gender, weight, age, co-morbidities, co-medications, allergies and pre-operative history, plus a host of genetic and environmental factors.

• The replacement of healthcare systems reliant on paper-based medical records or generally localized clinical information systems by very large scale health information infrastructures centred on interoperable electronic patient record systems is now underway in many western countries. These national programs, all established within the last few years, are so extensive that they will precipitate a healthcare revolution in each country where they have been announced.

• The Electronic Health Record (EHR) seems to be the ideal point-of-care solution for most clinicians to simultaneously improve quality and enhance operational efficiency. However, for various reasons, EHR adoption has been slow in the US and in the UK, particularly for physicians in small practices.

Early adopter case studies

Partners Healthcare

• Partners? information systems budget was $92.3m in 2002, monies that have been used to develop a number of knowledge assets, such as a suite of medication decision support systems which include expert systems for tailoring drug dosage regimens to specific patient groups such as the aged or cases of renal insufficiency, order sets for radiology, and outpatient decision support.

• Partners sees its current challenges as largely being driven by interoperability, knowledge management and performance issues.

• To combat these problems, Partners is investing in the development of a knowledge management system.

Adventist Health System (AHS)

• AHS? motivation for undertaking its ?evidence-based practice? program has been the improvement in quality of outcome and reduction of costs.

• Using Cochrane Library material, speciality medical Society consensus views and data from the national guideline clearing hous