Can Health IT Fix The Evidence Gap?

One of medicine's best-kept secrets is the embarrassing fact that about half of all medical treatments aren't supported by solid clinical research. A report from the Cochrane Collaboration, one of the most respected sources of expert analysis on scientific medicine, concluded that "the evidence did not support either benefit or harm" for 49% of clinical interventions. Why should this matter to IT managers?

For one thing, if you flip that statistic on its head, it means there's solid data to support 51% of available therapies. With that in mind, doctors and nurses need to be able to differentiate between what is and isn't supported by good evidence. Unfortunately, many clinicians are too busy to keep up with the research, and frankly some have a hard time distinguishing high science from voodoo medicine.

Feeding the right kind of data into your organization's clinical decision support (CDS) and computerized physician order entry (CPOE) systems is one of the best ways to help clinicians make informed decisions and ensure high-quality patient care.

Finding The Best Order Sets

There's a great deal of reliable data available to help clinicians make evidence-based decisions at the bedside, it's just not readily accessible, according to Jeffrey Rose, MD, VP of clinical excellence and informatics at Ascension Health in St. Louis.

At his hospital system, they started with a core set of evidence-based order sets, then collaborated across 114 hospitals, enlisting subject matter experts to help create a library of over 1,200 order sets and protocols, categorized into several "buckets." As he outlined in a presentation at this year's Healthcare Information and Management Systems Society (HIMSS) conference, those buckets were:

--Condition-based: acute myocardial infarction, for instance;
--Procedure-based: such as a lumbar puncture;
--Convenience-based: order sets geared for hospital admission, for example; and
--Specialty based: e.g., obstetrics-oriented.

Johns Hopkins Hospital, likewise, has its own approach to CDS. Hopkins has taken evidence-based CDS to a new level by creating smart order sets. A good example of this approach is the hospital's order set to prevent venous thromboembolism (VTE)--blood clots--in postoperative patients. Because VTE is so life-threatening, and because there are so many variables involved in choosing the best protocol to prevent it, Hopkins' IT department and clinical experts teamed to customize the order set.

"The precise components of the best preventive therapy ... [have] become too complex for physicians to remember. There are hundreds of different recommendations in these smart order sets that are nuanced by the patient's medical conditions or other therapeutic contraindications," explained Peter Greene, MD, Johns Hopkins' chief medical information officer, in an email.

Johns Hopkins' VTE order set requires physicians to work through a decision tree, stratifying post-op patients into different risk groups. The algorithm is "smart" because it provides the clinician with an easy-to-navigate checklist of relevant risk factors and contraindications for treatment. For example, the doctor has to tell the system if the patient had a previous VTE, if the operative procedure was longer than two hours, and if the patient was on bedrest for more than three days--all of which would increase the threat of a blood clot.

And then the system automatically populates the screen with VTE-relevant facts from the patient's chart, including his or her age, weight, and renal function. And finally it recommends the best, evidence-based preventive treatment.

Should You Bring A Vendor In?

Another approach to evidence-based CDS is to start with a well-respected, commercially available database that condenses the 100,000s of research studies into practical easy-to-follow clinical guidelines. UptoDate is one of the best. It covers over 8,500 topics, contains about 97,000 pages of text, enlists about 4,400 experts in 17 specialties, and is updated several times a year. Equally important, it has the respect of clinicians worldwide--about 450,000 of them use it.

Once your facility decides on a clinical database, the next step is to figure out how to plug it into the electronic health record (EHR), CDS, and CPOE systems. One way is to use a vendor that has already figured that process out. Provation, for instance, has married UpToDate's database to its order sets. They've done most of the legwork so that the order sets and UpToDate content can be integrated into your hospital's systems, using standards such as HL7 and InfoButton API, and the right terminology, including SNOMED CT, RxNorm, LOINC, CPT, and ICD-9.

No doubt, you'll encounter clinicians who object to evidence-based order sets no matter how smart they are. And they rightly point out that not all patient encounters can be neatly solved with a clinical guideline or algorithm. But most will realize that they need help filling the evidence gap.

Find out how health IT leaders are dealing with the industry's pain points, from allowing unfettered patient data access to sharing electronic records. Also in the new, all-digital issue of InformationWeek Healthcare: There needs to be better e-communication between technologists and clinicians. Download the issue now. (Free registration required.)