Problem: lack of connection to clinical guidelines

I’m at point 2 in the list of problems we need to solve. You can also find this text, possibly improved, on the iotaMed wiki.

As new discoveries are made in medicine, we need to get these out to “the factory floor”, so they are applied in practice. If there’s a new more efficient diagnostic method, or a treatment that cures more people with less side effects, we want the medical authorities to review this new knowledge as soon as possible, weigh costs against benefits, and then have it applied to clinical practice as soon as possible. This review then results in recommendations in a form that many prefer to call “clinical guidelines”. These guidelines strive to be a practical implementation of current knowledge, including diagnostic criteria, recommended diagnostic methods, recommended treatments, caveats, differential diagnoses (other possible diagnoses that should be considered), etc. The best clinical guidelines are regionalized and contain telephone numbers to individuals to consult, links to forms to use and more. Finally, we have to find a way to distribute these clinical guidelines in a way that they are effectively used in practice.

A recent review showed, however, that the average time between the research expenditure of a new medical discovery and the effective health benefits of it, is 17 years [1]. An important part of that is the delay between publication and actual application of that knowledge by physicians.

The classic solution to the problem of disseminating new discoveries is training, or CPEs (Continuing Professional Education). But that is highly inefficient for doctors for a number of reasons, including:

  • There are more relevant subjects to be trained in for a medical doctor than there are opportunities to get training, so it’s largely a crap shoot if you will be trained in something you’ll need often in practice
  • Knowledge fades if not used, so it’s even more of a crap shoot if you’ve been recently trained in a subject you need today

Now, even if I got trained last week for how to treat heart decompensation, I’m pretty certain to miss one or more steps in the fairly complicated clinical guideline if I got a patient today and did not have a copy of the guideline at hand. So there is also the list of details problem, the same problem airline pilots solved with checklists. No matter how many times they do landings, they’re bound to forget some little fatal switch sooner or later if they don’t run through pre-landing checklists. (For an excellent treatment of this subject as applied to surgery, do read Atul Gawande’s “The Checklist Manifesto”.)

Of course there are clinical guidelines everywhere, and that’s also a problem. They’re everywhere, except where you need them. When I see a patient with diabetes, I can’t take a trip to the library to read up on the clinical guidelines, there’s no time for that. And it would scare the sh*t out of the patient. I can, though, find the guideline at the local government site, if it’s there, or over there at the other site, maybe, um, nope, that one is old, or here at the… darn… what was that URL again? or… darn it, I know diabetes, I don’t need it. So maybe next time Uncle Bob comes along, I’ll remember to do that retinogram I should have done but forgot about since I didn’t find the guideline and couldn’t remember exactly how often it should be done. It changes, you know.

Let’s assume you do find the right clinical guideline and follow it. In that case, you want to continue to follow that same guideline when the patient shows up the next time, even if he is seen by somebody else. But there is no way to signal in the medical notes which guideline you are following. You could, of course, just paste in the URL right there, which I often do. There are two problems, though:

  • The URL isn’t generally clickable due to our poor EHR implementations, and they wrap, making a mess that the average doctor isn’t likely to want to understand or use
  • Some clinical guideline sites have the bad taste to still use IFRAMEs, so there is no URL available to go to the right guideline

Sometimes I simply copy in text from the guideline right in to the field “planning” in the notes, but it’s ugly. And it will soon become unread history due to the scrolling nature of the medical record. In other words, nobody will read it anyway.

Finally, I want you to consider how much suffering and needless expense we incur by treating patients using methods that are 17 years out of date and even then forgetting every so many steps of that diagnosis or treatment because we do it all from memory. It’s scary, isn’t it? Imagine if airlines worked like this. Terrorists would have nothing to do.

References
  1. Medical Research: What’s it worth? Estimating the economic benefits from medical research in the UK. Wellcome Trust, Medical Research Council, The Academy of Medical Sciences. Briefing November 2008. Short form and long form.