The evidence is in …

photo by Eric Tadsen

Tucked away in the landmark Patient Protection and Affordable Care Act is a provision that may contribute more to improving quality and lowering costs than the more controversial pieces that captured the public’s attention. If the new law does help bend the cost curve downward, it will be in no small measure to the additional funding for testing and implementation of evidence-based medicine initiatives, which already have proven their worth in an industry that was slow to the process-improvement party.

IB spoke to several area health care administrators and practitioners who offered testimony to the value of evidence-based projects, which have intensified since the 1999 Institute of Medicine report on hospital errors. Don Berwick, founder and CEO of the Institute for Health Care Improvement, is given the most credit for getting the industry to think systemically about continuous quality and process improvement, but local organizations have made their own contributions.

“One of the primary values of our renewed focus on evidence-based medicine is that we’ve had to acknowledge where the emperor has no clothes,” stated Dr. Frank Byrne, president of St. Mary’s Hospital in Madison. “We’ve had to acknowledge what we do that isn’t evidence-based and develop evidence that supports the best care.”

Putting on a Clinic

Part of the challenge of medical research has been the inability to translate it into the clinic, but a Madison evidence-based study is actually taking place in the clinic. Dr. Maureen Smith, a professor and researcher with UW-Madison, noted that most evidence-based studies pertain to drug or surgical efficacy, but she’s involved in a rare, clinic-level project. Smith, is the principal investigator on a project to evaluate and redesign the UW Health’s primary care work team. Thus far, the organization has funded the project internally, but it has applied for a comparative effectiveness grant to accelerate the implementation of improved primary care practices in areas like pre-visit preparation, waiting times, workflow — even the timing of lab work.

Smith contends the improvements will be more sustainable over time because they are being developed by the people — receptionists, nurses, physicians, and even patients — who practice them each day.

The primary care project may not be as compelling as UW Health’s research into treating conditions like deep vein thrombosis, but Smith said an exciting thing about the new health care law is that funding will be available for this. In Smith’s view, this work contributes to the evidence base, but it previously has not been supported like comparisons of drug therapies. “This is a very different way of contributing to the evidence base,” she said. “That’s the exciting part.”

Due to time limitations, it’s practically impossible for busy physicians and nurses to process all new evidenced-based information, so health care organizations use electronic medical records to “hardwire” order sets, guiding both diagnosis and treatment in their point-of-care workflows. To speed that process, UW Health has established a Center for Clinical Knowledge Management. “The hope is to rigorously evaluate the evidence underneath best practices, but more importantly, translate that into implementing the change,” said Mark Kirschbaum, senior vice president of quality and information for UW Health.

Group Health Cooperative of South Central Wisconsin also has electronic clinical decision support, but with best practice information provided by the U.S. Preventive Services Task Force. Since the evidence in clinical medicine is always changing, the organization works to keep its clinical decision support consistent with national recommendations. The effort is well worth it, according to Dr. Jessica Bartell, director of clinical and service quality for GHC-SCW. “It’s critical that evidence-based medicine has its rightful place as a priority in defining our new health care system because we can spend a lot of money producing tests and giving out medication, but if we don’t know what the appropriate care is, then we can’t produce the health outcomes we want, and we can’t do it in an efficient way.”

Christine Baker, administrative director for quality and safety systems at St. Mary’s Hospital, said a variety of health care professionals — nurses, microbiologists, pharmacists, epidemiologists — helped develop a new evidence-based criteria for the timely removal of Foley catheters, but it wasn’t until the installation of its electronic medical record in 2008 that it could build those criteria into nursing flow sheets. Thanks to the EMR, it was able to share them with with 20 hospitals in the SSM Health Care system.

The business case for preventing infections is two-fold: saving the extra cost an infection would bring, and ensuring Medicare reimbursement. The Medicare program is taking a dim view of paying for preventable health events, and even though St. Mary’s outperformed the national average in the incidence of urinary track infections, it did not know whether it was getting optimal results. “It was the advent of the electronic record that really let us optimize an evidence-based practice guideline that had been developed before, but which we really weren’t able to get much traction with,” Baker said.

Unbiased Drug Buys

The federal government is not the only entity that can drive improvement. In Wisconsin, legislation has been introduced to help physicians take advantage of academic detailing in the area of prescription drugs. The bill would require the state Department of Health Services to develop and implement an evidence-based medication system that gives drug prescribers unbiased pharmaceutical information, rather than having to rely solely on pharmaceutical sales people who have an incentive to push their products.

Nino Amato, president and executive director of the Coalition of Wisconsin Aging Groups, said states like Pennsylvania already have access to such a system, and they are better able to control drug costs. The system provides information about name brand versus generic and which drugs should not be taken in combination. “The whole issue is really about having a non-biased informational system,” Amato noted, “and not be pushed around by the pharmaceutical system.”

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