January 18, 2020

Empowering Physicians at the Point of Care using Digital Clinical Guidelines and Pathways

Empowering Physicians at the Point of Care using Digital Clinical Guidelines and Pathways

If you are a hospitalist or primary care physician who cares about these issues, please contact me at shaker118@gmail.com to get involved with our efforts to help guidelines be more useable at the point of care.

7 years ago, I was done being a miserable primary care doctor in Egypt. I packed my bags and left my whole life behind me with not much more than hopes and dreams of how practicing in the US would help me fall in love with medicine once again. I was lucky enough to find an internship position at the prestigious Tufts New England Medical Center, and had the most incredible doctors and learning environment. It didn’t take me long to realize however, that doctors in the US operate by different rules, and that these rules created equal misery. The issue fo quality of care became of interest to me as I felt constantly overwhelmed by the amount of “Evidence Based” guidelines and wondered how a physician can remain up to date amidst the madness of the job.

Now more than ever we expect physicians in the United States to provide the highest quality of care at the lowest cost possible. While they figure that out, we demand that they document every step, strictly follow potentially biased guidelines and reject their payments if they don’t comply. Imagine being a ride-sharing app driver where every client of yours requires a luxury limo at the price of a used Honda Civic, and to get paid you needed to fill 30 mins of documentation. Oh and if you take a wrong turn, its very likely that you’d get sued. Would you keep driving? I didn’t. Within a year I decided to switch careers into clinical informatics and have since obsessed about how data can empower physicians to love their work again.

Medical providers are not business people. We run on the currencies of mastery, autonomy and relatedness to our patients and the jolt of ecstasy that we get from healing them. In medical school, we learn to be hyper-competitive each one of us takes pride in the knowledge we've been able to accumulate and text-books we have been able to digest. When thrown in the real world though, with this demand of quality, how can physicians stay up-to-date and deliver the best possible quality for a specific episode of care? That is what I am dedicated to figuring out.

There is a lot more than sound clinical research that goes into what makes a good clinical decision, including a physician’s experience, understanding of the patient’s psychology, and more nuanced factors such as human intuition. In my next blog post, I will address the multiple layers that go into clinical decisions, but for now I want to explore how we can get the baseline evidence based guidelines into clinical practice and how that might empower physicians and help make their lives a little easier.

The healthcare system currently expects physicians to quantify quality through metric reporting based on clinical guidelines, popularized by the Institute of Medicine and later on by other medical associations such as the AMA, AAFP and AHRQ. Despite being beaten into MDs during internships and residency, these guidelines continue to have low or moderate adoption. There are several reasons why that is the case.
Some of these reasons are:
Not Individualized: Guidelines do not pertain to an individual patient. Some doctors dub this “Cook Book Medicine” which makes medicine impersonal and not contextual.
Overwhelming: The amount of research can be overwhelming and no physician can keep up with the estimated 2000 papers published everyday!
Trust: Physicians don’t always trust guidelines because evidence comes in various sizes and some of them do not indicate the GRADE scoring which defines whether it is an expert opinion or a proper randomized control trial.
User Experience: The guidelines are locked into paper based formats or standalone pdfs that are not realistic to refer to at the point of care

The fact that these guidelines are not useable does cause huge healthcare problems such as medical errors, unnecessary lab/imaging orders and over-treatment. Multiple research studies have been done to see if computerized versions of these guidelines can help engage doctors more and provide better patient outcomes. The answer so far is a unanimous yes. Studies have shown a two-fold increase in clinician compliance with care guidelines for diabetes mellitus, evidence showed that the use of CCG seems to have a significant impact on the process of care, and that the use eClinical Guidelines is particularly useful in good control and secondary prevention of chronic diseases particularly heart failure and hypertension.

So where does that leave us? How do we arm physicians with the right guidelines at the right time during the point of care, instead of forcing them to report on metrics and follow guidelines that might not make sense to them? How might we enhance the usability of the growing body of research at the point of care when it is needed the most? If we stop blaming doctors and start providing them with effective clinical decision support tools, can we improve the quality of care and outcomes for patients?

If you are a hospitalist or primary care physician who cares about these issues, please contact me at shaker118@gmail.com to get involved with our efforts to help guidelines be more useable at the point of care.

References:

https://www.amjmed.com/article/S0002-9343(96)00382-8/abstract

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2837004/#!po=36.9565