Translating Evidence into Practice 1998 (continued, 2)
Introductory Remarks: How AHCPR is Making a Difference
John M. Eisenberg, M.D., M.B.A., Administrator, AHCPR
Dr. Eisenberg cited some of AHCPR's accomplishments:
- Outcomes research has been firmly established with guidelines recognized as one tool.
- Evidence-based Practice Centers have been established around the country and in other countries.
- The U.S. Preventive Services Task Force, which made initial recommendations that were implemented in Put Prevention Into Practice, is now AHCPR's responsibility.
- The National Guideline Clearinghouse™ is online.
- AHCPR has helped establish the role of evidence in measuring consumer satisfaction through the Consumer Assessment of Health Plans survey.
- AHCPR has demonstrated serious gaps in care provided to certain groups of Americans, especially Americans of color.
AHCPR is looking forward to continuing to work with practitioners and colleagues within the Department of Health and Human Services (HHS) to translate evidence about clinical practice and organizational change and challenges facing the United States into practice. AHCPR hopes to make a difference by providing better access to health care that is of very high quality and is the best that the evidence allows U.S. practitioners to provide.
Opening Remarks: Priorities of the Surgeon General
David Satcher, M.D., Ph.D., Assistant Secretary for Health, U.S. Surgeon General
Dr. Satcher stated that a commitment to science and to science-based decisionmaking is the principle that has guided the Public Health Service since its founding in 1798. Today, the priorities of the Surgeon General's office include:
- Every child must have a healthy start in life.
- Promoting healthy lifestyles includes emphasis on healthy concerns and barriers.
- Attitudes toward promoting mental health need to be improved.
- Better understanding of the health care system is needed to access quality health care for reasonable cost.
- HHS requires commitment to eliminate disparities between the health statistics of Caucasians and people of color. This commitment will be concentrated in the areas of infant mortality, immunization, HIV/AIDS, cardiovascular diseases, diabetes, and cancer.
Keynote Address: Clinical Judgment and Evidence-based Medicine
W. Scott Richardson, M.D., Assistant Professor Medicine, University of Texas Health Science Center at San Antonio
Dr. Richardson noted that there are five steps in practicing evidence-based medicine: (1) translating information needs into an answerable question, (2) searching for the evidence, (3) appraising that evidence, (4) using the evidence in the actual care of patients or for policy decisions, and (5) evaluating the results of using the evidence.
Clinicians use a wide range of judgment, decisions, actions, and recommendations, including:
- Clinical expertise—everything physicians know from their practice; good observational powers.
- Patient perspective—empathy, compassion, and respect.
- Context of care—patterns within the community.
- Human biology—understanding of how things work.
- Clinical care research—ability to spot fair comparisons as well as understand how numbers can be applied to the clinical setting.
Lessons learned about the use of judgment include:
- Pay explicit attention to clinical judgment in practice and in teaching.
- Develop tools for better understanding and use of clinical care research evidence.
- Celebrate making and translating knowledge for use in clinical work.
- Use the "judgment test"; ask, in the end, with this material, would someone be in a better position to use their professional judgment?
- Learn by imitation and evaluation.
In thinking about clinical judgment and use of evidence, Dr. Richardson concluded that people should: encourage the use of judgment, rather than mindlessly following the rules; support the creation and the synthesis of knowledge; support the translation of knowledge, making it understandable and usable and add wisdom along the way; support the dissemination of knowledge; support actual practice; and use the "judgment test."
Using the Internet to Improve Knowledge Diffusion in Medicine
Edward H. Shortliffe, M.D., Ph.D., Professor of Medicine and of Computer Science, Stanford University
Computer-based medical records, tied to some kind of feedback process, are a key need. Dr. Shortliffe suggested that using the Internet to obtain feedback is helpful, but effective use of the Internet for decision support requires integration of the rich information environment with the electronic patient record.
Integrated clinical workstations lie at the core of efforts to provide pertinent information and decision support at the point of patient care. Integrated clinical workstations will have clinical applications of results, which will include reporting order entry, transcribed report access, telemedicine (maybe with video consultation), and the patient record. Administrative information will include admissions/discharges, materials management, personnel, and costs. Research and decision support will include clinical pathways, research protocols, clinical trials, techniques for capturing outcomes, and quality assurance. Scholarly information will emanate from the local library, drug information sources, and the Web. Office automation will include E-mail, spreadsheets, and word processing.
Clinical workstations will also be connected to patients and to clerical workstations. Called "enterprise intranets," these connections link heterogeneous machines so they can communicate with each other and so standards can be established for data exchange and integration. Once the organization is linked from within, linkage to the outside world is the next challenge.
On the Web, many sources exist, both carefully reviewed and maintained sites and questionable information sources. In addition to judging how to assess the quality of the information, other challenges for clinicians are: how to access the Internet at the time and place when the information is needed; how to find pertinent information once the connection has been made; how to be efficient especially in a patient-care setting (with limited time); how to navigate the pertinent Web sites once they are found (how not to get lost); and how to determine the relevance of the information to the patient.
The Internet's future is already being shaped:
- The Connections Program of the National Science Foundation: A very high bandwidth network system (vBNS), to connect supercomputers.
- Internet 2: A consortium of academic and research institutions, recently incorporated into University Consortium to Advance Internet Development (UCAID).
- Next Generation Internet (NGI): A Federal program across several agencies to promote research on pushing the Internet forward.
Much information is available but integration issues have not yet been well addressed. Some emerging integrated sources are the American College of Physicians at http://www.acponline.org and Ovid (for access to the evidence-based medicine collection) at http://www.ovid.com
Implementation: 10 Years of Success and Failure
Scott Weingarten, M.D., M.P.H., Director of Health Services Research, Cedars-Sinai Health System
Dr. Weingarten discussed how the Cedars-Sinai Board of Directors quality imperative policy sets measurable standards for quality of care for all Cedars-Sinai Health Services (CSHS)-affiliated organizations. These standards are determined by CSHS physicians and other clinicians and must be clinically meaningful, up-to-date, and attainable. Programs are created to assist CSHS physicians and other providers in meeting these standards whenever possible.
In contrast, educating physicians about guidelines may be futile because few physicians remember what the guidelines actually say, even though much resources and time are spent generating them. In analyzing factors that led physicians to reject a practice guideline, researchers found that physicians strongly dislike guidelines. Researchers also found that the guidelines were rejected primarily because the physicians discerned clinical nuances that rendered the guideline inadvisable for a particular patient.
For the future, Dr. Weingarten said we must try to achieve a better balance between having a macro impact (measurable at an organizational level or a public health level) and preserving focus and measurement. Health care organizations that survive will do so because they understand the best possible care, where they stand currently in relation to best care, and how to close the gap between the two.