Nels Leininger, M.D., an internist at the South Bend (Ind.) Clinic, had to wait until his patients with high blood pressure came for office visits before he realized they were not taking their medications regularly.
Now he doesn't leave it to chance. Instead, he receives electronic messages from a program called Clinical Alert Systems as a reminder to follow up or to let him know other information, such as a patient with diabetes who needs an eye exam.
The system, which promotes evidence-based medicine (EBM), makes sure treatment for a specific patient complies with accepted standards of care.
Developed by Health Resolution Strategy in San Jose, Calif., Clinical Alert Systems is based on published national guidelines and assessment algorithms, with rules coming from multiple journals and other sources.
By relying on claims and pharmaceutical data from health plans, HRS is able to identify noncompliance with standards of care.
"The clinical alerts are a nonthreatening way to remind us to ask our patients whether they have taken their medications or to schedule a liver function test for someone on lipid medicine," Leininger says.
Clinical Alert Systems covers those of his patients who are enrolled in Partners National Health Plan of Indiana, about 10% of his practice. Leininger praises the system because he says some doctors only look at a single episode of care.
"A tickler system is helpful and improves the chances of a patient getting the care he or she needs," he says, adding the alerts are not an indication that doctors aren't doing their jobs.
Clinical Alert Systems is just one of many examples of EBM, a method for applying current best knowledge to healthcare decisions.
Paul Wallace, M.D., executive director of the Care Management Institute at Kaiser Permanente in Oakland, Calif., says EBM is a "process of ensuring that we are being as rigorous as we can about sharing data that is consistent, honest and reproducible with physicians. EBM offers a better way to organize and access the breadth of evidence that is now available. It is a refinement of what clinicians have always done but offers a way to prioritize knowledge and to establish a relationship between knowledge and care."
EBM may take the form of guidelines, disease management protocols, best practices, definitions of medical necessity, performance measurements and targets, pharmaceutical formulary policies and establishment of strategic goals.
David Eddy, M.D., an independent adviser and advocate of EBM, has definite ideas about the use of EBM. "When there's evidence that something is good and benefits the patient, we should do it; when there is evidence that there is no benefit and something is of poor value, we shouldn't do it. When we don't know, we should be conservative," he says.
He also notes that a new treatment should be done only within the context of a clinical trial and that an old treatment, while still an option, should proceed on a case-by-case basis if it's not promoted through an affirmative guideline.
"If you don't know the benefits, but do know the potential for harm--side effects, risks--or if it's not cost-effective, discourage it," he says.
Eddy says most healthcare organizations claim they practice EBM; however, few of them, along with physicians, actually do so based on his description of the effect of evidence of treatment.
"The main breach is that physicians continue to do lots of things for which there is little evidence," he says. As for the cost savings, Eddy says, "There are no claims that it cuts costs, but if we stop doing things we shouldn't be doing or do things we should be doing and improve processes, there is a potential to save money."
One would hope that medicine is already evidence-based. Eddy is concerned that many clinicians assume that time-honored standards of care are effective and cautions them to be more skeptical. He notes that standard practices can vary widely from one healthcare system to another and from city to city. Reducing this variability is one of the main objectives of EBM.
On the other hand, Eddy has no explanation for why some clinicians don't follow guidelines that have proven effective, such as giving ACE inhibitors to patients who have suffered a heart attack. According to the American Heart Association, only 31% of patients with congestive heart failure received ACE inhibitors between 1989 and 1994, based on 110,000 office visits.
That's not to say that clinicians should be tied to guidelines, however; instead, EBM should serve as a tool to enhance decisionmaking, some physicians say. "If a clinician is doing everything right--talking to patients, presenting options--decisions often require the 'art' of medicine," Eddy says.
To Scott Weingarten, M.D., CEO of Zynx Health, a subsidiary of Cedars-Sinai Health System in Los Angeles, EBM is knowledge that can be beneficial or misused. "EBM is an acknowledgment that care in the United States is not consistent with the best scientific evidence and not producing the best outcomes. In some cases, life-saving therapies are underutilized, and certain drugs which have not proved beneficial are overutilized." Informing doctors on a real-time basis at the point of care is imperative and a challenge, Weingarten says.
At the request of many of its members, Irving, Texas-based VHA, a nationwide network of community-owned healthcare systems and their physicians, last year established the Clinical Advantage program. Its goal is to improve patient outcomes through the use of evidence-based knowledge and standardized measurement. It addresses improvements in the treatment of heart attacks, breast cancer, congestive heart failure and strokes, as well as medication error reduction, patient safety and, soon, pain management.
Clinical Advantage is based on the premise that doctors do best when they experience learning, says Nancy Wilson, M.D., vice president of clinical affairs for VHA. "They can read peer-reviewed journals but not actually implement what they read," she says. "To make improvements in care, clinicians really need coaching, tools and strategies."
With that in mind, VHA organizes teams of physicians in their local communities and combines improvement methodologies with assessment tools, education, coaching, standardized measurements and knowledge sharing.
After an initial workshop, participants meet again to report their successes and problems. They also meet with local VHA coaches for follow-up. So far, more than 825 physicians have participated.
Before VHA's stroke initiative with 50 participating healthcare organizations, only 11% of the groups' patients received TPA treatment within three hours of a stroke; this jumped to 34% due to an EBM protocol initiated in all of the organizations.
In addition, the time from door to CT scan decreased from 83 to 57 minutes, a 31% drop. For acute myocardial infarction, 59% of patients received a beta blocker within 24 hours of arrival, which increased to 72% due to an established protocol with 30 hospitals participating.
Alan Rosenstein, M.D., VHA West Coast vice president/medical director, believes Clinical Advantage's multidisciplinary team approach engenders commitment from top to bottom in each organization and removes barriers to physicians' adherence to practice guidelines.
He believes one of the most important issues is how EBM is sold to the physician. At VHA, the regional collaborative model has proven less threatening to doctors than other strategies.
Sacramento, Calif.-based MedClinic Medical Group, a 150-physician multispecialty practice, has been working with its physicians to ensure that they are doing the right thing at the right time, says Jennifer Nuovo, M.D., associate medical director for managed care. "It's not always easy to provide quality, cost-effective care when you are bombarded with so many options," she says.
"When you are practicing in a general field such as internal medicine, a physician doesn't always have the ability to analyze every problem based on what he or she has learned from CME conferences or read in the medical literature, especially when you see 25 patients a day each for less than 15 minutes."
MedClinic has developed some of its own guidelines, brought in specialists to discuss treatments, relied on nurse care management teams to remind patients to take medications and conducted physician workshops and patient education programs.
Some are debating the effect EBM might have on the physician/patient relationship. Weingarten, like many of his colleagues, believes that EBM should be shared with patients to not only trigger productive discussions with their doctors, but also to provide more opportunity to make decisions about their healthcare.
Nuovo also would like to see her physicians develop collaborative relationships with their patients and discuss treatment options.
Wallace believes that EBM "allows us to be honest with patients about the expectations of an intervention, the risks and benefits, and help make them key participants in their healthcare. A clinician has to share uncertainty with a patient, but that doesn't necessarily mean not to offer a particular treatment."
His advice is to pursue all relevant literature related to a clinical topic; grade the reliability of the literature; determine if the available information is rigorous enough to draw conclusions; and, if evidence is adequate, decide if it provides benefit and if better alternatives exist.